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CLINICAL    LECTURES 


ON 


MENTAL    DISEASES 


CLINICAL    LECTURES 


MENTAL    DISEASES 


BY 

T.  S.  CLOUSTON,  M.D.  Edin.,  F.R.C.P.E  , 

VHYSICIAN-SUPEEINTENDENT  OF  THE  EOYAL  EDINBURGH  ASYLUM  FOE  THE  INSANE, 

LECTURER  ON  MENTAL  DISEASES  IN  THE  UNIVERSITY  OF  EDINBURGH, 

FORMERLY  CO-EDITOR  "JOURNAL  OF  MENTAL  SCIENCE"   AND  MORISON   LECTURER, 

AUTHOR  OF  "  THE  NEUROSES  OF  DEVELOPMENT." 


FOURTH  EDITION. 


LEA  BROTHERS  &  CO., 

PHILADELPHIA   AND   NEW   YORK 
1897. 


PREFACE  TO   FOURTH  EDITION. 


A  Medical  Book  that  is  coining  out  in  its  Fourth  Edition 
should  need  no  Preface.  The  demand  for  it  has  absolved  its 
Author  from  any  further  explanation  of  its  existence.  That 
it  was  needed,  and  has  so  far  supplied  a  need,  might  be  held 
as  proved;  and  this  should  be  sufficient  proof,  too,  of  its  merits 
and  exculpation  enough  of  its  faults. 

The  study  of  Mental  Disease  is  now  entering  on  a  new  era. 
It  has,  for  the  first  time,  become  compulsory  on  all  medical 
students.  This  should  vivify  and  stimulate  the  teaching  of 
it,  and  affect  the  study  and  investigation  of  the  subject  in 
ways  and  degrees  as  yet  unknown  to  us.  To  us  teachers  the 
change  will  not  be  entirely  a  gain.  For  our  delightful  optional 
classes  will  be  substituted  larger  compulsory  gatherings.  The 
moral  relationship  of  teacher  and  taught  will  no  longer  be  the 
same.  The  subtile  aroma  of  perfect  freedom  to  teacher  and 
taught  will  be  gone.  The  charm,  on  both  sides,  of  feeling 
that  here  at  least  there  was  no  shadow  of  the  upas  tree  of 
impending  examination  to  poison  the  air  will  have  disap- 
peared. Fortunately,  the  subject  lends  itself  to  teaching  in 
which  every  intelligent  student  will  be  more  or  less  interested. 
I  have  always  maintained  that  no  subject  in  his  course  will 
keep  the  average  student  so  mentally  alert  during  an  hour  of 
a  sultry  summer  afternoon  as  a  good  clinical  lecture  on  mental 
diseases,  well  illustrated  by  patients.  I  trust  we  teachers  will 
be  enabled  now,  more  than  ever,  to  present  to  our  students, 
in  addition  to  the  details  of  our  subject,  the  relationship  of 


VI  PEEFACE. 

the  disturbed  mental  functions  of  the  brain  to  general  Medicine 
and  Surgery,  and  so  prevent  our  department  from  sinking  into 
a  specialty  in  the  bad  sense.  Mind  and  brain,  dominate  all 
else  in  the  organism;  and  their  diseases,  if  properly  studied, 
can  never  be  narrowing. 

In  regard  to  how  this  Edition  differs  from  the  last,  I  can 
only  say  that  I  have  endeavoured  to  embody  in  it  the  advances 
in  our  knowledge  that  have  taken  place  during  the  past  four 
years.  I  have  especially  directed  attention  to  the  important 
therapeutic  measure  of  using  thyroid  extract  in  certain  cases 
of  insanity,  in  the  way  devised  by  Dr  Lewis  Bruce,  now  one 
of  our  medical  staff  here.  I  have  taken  advantage  of  the 
original  pathological  work  done  here  in  that  time  by  Drs 
Middlemass  and  "W.  F.  Eobertson..  Dr  Eobertson  has  been 
good  enough  to  draw  for  me  the  new  Plates,  XIII.,  XIY,,  and 
XY.,  to  illustrate  typical  changes  in  the  cortical  cells,  fibres, 
neurogha,  and  vessels,  in  certain  important,  forms  of  insanity  : 
changes  that  I  endeavour,  by  Dr  Eobertson's  aid,  to  show  to 
my  classes  by  demonstrations  of  the  actual  sections  under  the 
microscope,  and  by  micro-photographs  thereof  exhibited  by 
means  of  the  lantern.  These  gentlemen,  with  Drs  Bruce  and 
Easterbrook,  I  have  to  thank  for  willing  assistance  and  sug- 
gestions in  getting  this  Edition  through  the  press. 


CONTENTS. 


LECTURE  I. 

PAGE 

The  Clinical  Study  of  Mental  Diseases,     ...  1 


LECTURE  II. 

States  of  Mental  Depression— Melancholia  (Psychalgia),        25 

LECTURE  III. 

Melancholia  (Psychalgia) — continued,  .  .  .81 

LECTURE  IV. 

States  of  Mental  Exaltation— Mania  (Psychlampsia),        .      136 

LECTURE  V. 

States  of  Alternation,  Periodicity,  Remission,  and  Re- 
lapse in  Mental  Diseases  (Folie  Cieculaire,  Psycho- 
rhythm,  FoLiE  A  Double  Forme,  Circular  Insanity, 
Periodic  Mania,  Recurrent  Mania,  Katatonia),         .      218 

LECTURE  VI. 

States    of    Fixed    and    Limited    Delusion,    Monomania 

(Monopsychosis,  Paranoia),  ....      250 

LECTURE  VII. 

States    of   Mental    Enfeeblement   (Dementia,  Amentia, 

Psychoparesis,  Congenital  Imbecility,  Idiocy),  .      278 


Vlll  CONTENTS. 


LECTURE  VIII. 

PAGE 

States  of  Mental  Stupor  ("  Acute  Dementia,"  "Primary 

Dementia,"  "  Dementia  Attonita,"  Psychocoma),        .      304 


LECTURE  IX. 

States  of  Defective  Mental  Inhibition  (Impulsive  In- 
sanity, Volitional  Insanity,  Uncontrollable  Impulse, 
Psychokinesia,  Hyperkinesia,  Inhibitory  Insanity, 
Insanity  without  Delusion,  Exaltation  or  Enfeeble- 
ment.  Affective  Insanity).    The  Insane  Diathesis,     .      327 

LECTURE  X. 

General  Paralysis  (Dementia  Paralytica),  .  .  .      377 

Paralytic  Insanity  (Organic  Dementia),       .  .  .      418 

LECTURE  XI. 

Epileptic  Insanity,         ......      434 

Traumatic  Insanity,       .  .  .'  .  .  .      458 

LECTURE  XII. 

Syphilitic  Insanity,       ......      463 

Alcoholic  Insanity,        ......      479 

LECTURE  XIII. 

Rheumatic  and  Choreic  Insanities,    ....      493 
Gouty  or  Podagrous  Insanity,  .  .  .  .      503 

Phthisical  Insanity,      ......       504 

LECTURE  XIV. 

Uterine  or  Amenorrhceal  and  Ovarian  Insanity,    .  .      521 

Hysterical  Insanity,     ......      527 

Insanity  of  Masturbation,       .....      531 

LECTURE  XV. 

Puerperal  Insanity,      ......      543 

Insanity  of  Lactation,  ......      560 

Insanity  of  Pregnancy,  .  .  .  .  .567 


CONTENTS.  ix 

LECTURE  XVI. 

PAGE 

The  Developmental  Insanities. 
The  Insanities  of  Puberty  and  Adolescence,  .  .       575 

LECTURE  XVII. 

The  Insanities  of  Decadence. 

Climacteric  Insanity,     .  .  .  .  .  .610 

Senile  Insanity,  .  .  .  .  .  .621 

LECTURE  XVIII. 

Rarer  and  Less  Important  Clinical  Varieties 
OF  Mental  Disturbance. 

Anaemic  Insanity. — Diabetic  Insanity. — Insanity  of  Bright's  Dis- 
ease.— Insanity  of  Oxaluria  and  Phosphaturia. — Insanity  of 
Cyanosis  from  Bronchitis,  Cardiac  Disease  and  Asthma. — 
Metastatic  Insanity. — Post-febrile  Insanity. — Influenza  and 
its  Mental  Relationships. — Insanity  fi'om  Deprivation  of  the 
Senses. — Insanity  of  Myxcedema. — Insanity  with  Exoph- 
thalmic Goitre. — Delirium  of  Young  Children. — Insanity 
of  Lead  Poisoning. — Post-connubial  Insanity. — Pseudo- 
Insanity  of  Somnambulism. — Insanity  following  Surgical 
Operations,      .  ,  .  .  .  .  .650 

LECTURE  XIX. 

Medico-Legal  and  Medico-Social  Duties  of  Medical  Men 

IN  Relation  to  Insanity,     .....       669 

LECTURE  XX. 

A  Summary  of  the  General  Treatment  and  Management 
OF  Insanity  looked  at  as  a  whole,  and  on  the  Use  of 
Hypnotics,  Sedatives,  and  Motor  Depressants,  .       690 


Description  of  Plates,  ....  729-742 


DESCRIPTIO]^  OF  THE  PLATES, 


PLATE  PAGE 

I .  {Frontispiece).  — Appearance  of  the  vertex  of  one  hemispheie 

of  the  brain  in  a  case  of  very  advanced  General  Para- 
lysis, a,  Skull-cap  condensed,  b,  Anterior  third  of 
brain,  as  seen  when  dnra  mater  was  first  raised,  show- 
ing thickened  milky  arachnoid  dotted  over  with  small 
white  spots,  with  the  opaque  turbid  compensatory  fluid 
under  it,  and  the  tortuous  dilated  veins  and  congested 
vessels,  the  convolutions  showing  dimly  through. 
c,  Middle  third  of  brain,  showing  the  appearance  of  the 
convolutions  after  the  pia  mater  has  been  removed. 
They  are  congested,  and  the  outer  layers  of  grey  sub- 
stance have  been  torn  away  in  irregular  patches,  from 
the  most  projecting  part  of  many  of  the  convolutions 
having  adhered  to  the  pia  mater  and  been  removed 
with  it.  The  portions  so  removed  have  left  ragged 
eroded-looking  spaces  where  the  grey  substance  looks 
softened,  while  the  outer  layer  looks  rather  hard  and 
opaque  on  its  surface,  cl,  The  pia  mater  stripped  from 
middle  third  of  brain,  hanging  down,  concealing  poste- 
rior lobe  of  brain,  and  showing  the  appearance  of  its 
inner  surface  with  the  portions  of  the  convolutions 
adhering  to  it.  It  is  congested  and  thickened,  so  that, 
instead  of  being  like  the  normal  pia  mater,  a  delicate 
filmy  transparent  membrane,  it  is  a  tough,  thick, 
spongy-looking  texture. 

II.  Five  Microscopic  Drawings,  showing  pathological  changes 

in  (1)  Semi-lunar  Ganglion  ;  (2)  Cortex  ;  (3)  Epithe- 
lium of  Ventricle  ;  (4)  Artery  ;  (5)  Cortex  (atrophy),  729 
III.  Facsimile  of  a  letter  written  by  a  maniacal  patient,  show- 
ing incoherence,  rapid  change  of  ideas,  delusions, 
hallucinations  of  sight,  an  insane  association  of  ideas, 
and  an  insane  symbolism,         ....       730 


XU  DESCRIPTION   OF   THE    PLATES. 

PLATE  PAGE 

IV.  Irregular  Vascularity  of  Anterior  Lobe  of  Brain  from  a  case 

of  Acute  Mania,  .  .  .  .  .731 

V.  A  Chart  showing  the  Relative  Prevalence  of  Melancholia, 

Mania,  and  General  Paralysis,  .  .  .       732 

VI.  Great  and  Irregular  Thickening  of  the  Skull-cap  in  a  Case 

of  Chronic  Insanity  with  Brain  Atrophy,  .  .       733 

VII.  Absorption  of  White  Substance  of  Brain  due  to  Syphilitic 

Arteritis  ;  with  Persistence  of  Grey  Matter,    .         ■    .       734 
VIII.  Microscopic   Drawings   of   Cortex  in   a   Case   of  General 

Paralysis  and  a  Case  of  Chronic  Mania,  .  .       735 

IX.  Microscopic  Drawings  of  Cortex  in  Two  Cases  of  Epilepsy,        736 
X.  Standard  Types  of  Palate,  and  Specimens  of  Neurotic  and 

Deformed  Palates,         .  .  .  ,  .737 

XL  Sections  of  Standard  Palates,  ....       738 

XII.  Sections  of  Palates  in  Adolescent  Insanity,  ,  .       739 

XIII.  Six   Microscopic    Drawings   illustrating    the    Progressive 

Stages  of  Pigmentary  and  Granular  Degeneration  in 
Cells  of  Brain  Cortex,  .....       740 

XIV.  Two  Microscopic  Sections  of  Cortex  in  General  Paralysis, 

showing  Changes  in  Pia,  Capillaries,  Neuroglia,  and 
Nerve  Cells,      ......       741 

XV.  Ten  Microscopic  Drawings,  showing  Changes  in  Capillaries, 

Arterioles,  and  Cells  in  General  Paralysis,  Alcoholic 
Insanity,  Epileptic  Idiocy  in  contrast  with  Foetal  and 
Normal  Cells,  Senile  Insanity,  and  Secondary  De- 
mentia, ......       742 

Fuller  descriptions  of  these  Plates  are  given  opposite  each. 


CLIJ^ICAL 

LECTURES  ON  MENTAL  DISEASES. 


LECTUEE   I. 

THE  CLINICAL  STUDY  OE  MENTAL  DISEASES. 

Clinical  and  physiological  study  of  Mind — Temperaments  and  diatheses 
— Education — Heredity — Mind  influenced  by  other  Organs  than 
Brain — Alimentation — Reproduction  and  its  Mental  relationships — 
Clinical  mode  of  studying  Mental  Symptoms — Nomenclature  of 
Mental  Diseases — Classification  of  Mental  Symptoms — Skae's  Clinical 
Classification — Some  important  Anatomical,  Physiological,  Psycho- 
logical, and  Pathological  considerations  to  be  kept  in  mind  in  the 
study  of  Mental  Diseases — The  Method  of  Examining  a  Patient 
supposed  to  be  Insane,  and  the  Rules  to  be  Observed — Home  or 
Asylum  Treatment. 

Temperaonent  and  Diathesis. — The  student  of  mind  from 
the  cUnical  and  physiological  points  of  view  is  met  on  the 
very  threshold  hy  the  obvious  fact  that  it  differs  enormously 
in  its  normal  manifestations  in  different  persons  and  sexes, 
in  different  stages  of  life,  and  in  different  races.  He  sees, 
too,  that  it  is  manifestly  influenced  by  the  other  functions  of 
the  organism,  and  the  organs  through  which  those  functions 
are  performed.  These  facts  prepare  him  to  accept  to  some 
degree,  at  least,  the  generalisations  that  previous  students  of 
the  subject  have  made  as  to  the  existence  of  different  mental 

A 


2  CLINICAL   STUDY   OF   MENTAL   DISEASES. 

types  in  persons  of  the  same  and  different  ages  and  races, 
types  associated  with  bodily  characteristics — the  doctrines  of 
temperaments  and  diatheses.  He  sees,  for  example,  that 
there  are  certaia  persons  in  whom  the  nervous  functions  are 
very  active,  and  seem  specially  to  dominate  the  other 
functions.  Such  persons  are  hypersensitive,  move  quickly, 
and  think  clearly,  these  qualities  being  impressed  on  the  form, 
contour,  and  nutrition  of  the  whole  body.  He  soon  comes  to 
observe  that  persons  with  such  a  neurotic  diathesis  are  Hable 
to  diseases  special  to  themselves,  and  that  when  they  suffer 
from  ordinary  diseases,  the  neurotic  predominance  in  their 
constitutions  often  affects  the  character  and  duration  of  such 
diseases,  l^o  physician  of  experience  but  knows  that  insanity, 
neuralgia,  hysteria,  paralysis,  and  convulsions  are  more 
common  among  persons  of  tliis  type  and  their  cliildren  than 
among  the  general  population.  It  is  a  well-known  fact  that 
in  certain  cases  of  this  type,  acute  rheumatism,  for  instance, 
will  attack  the  brain  and  cord  rather  than  the  joints,  producing 
coma  or  chorea,  and  that  even  the  syphilitic  poison  will  by 
preference  attack  the  neuroglia  in  such  neurotic  constitutions, 
and  that  when  such  people  suffer  from  fevers  they  are  very 
apt  to  be  delirious. 

Education. — We  find  that  not  only  heredity,  temperament, 
and  diathesis  must  be  taken  into  account,  but  also  the 
education  the  brain  has  been  subjected  to.  I  commonly  find 
the  best  marked  "  types "  of  mental  disease  among  my 
educated  patients.  The  disease  is,  in  fact,  far  more  speciahsed 
among  the  educated  and  hereditarily  cultured.  It  is  often  a 
matter  of  keen  regret  to  me  that  for  clinical  teaching  I  am 
not  able  to  show  the  fijiest  examples  of  disease  to  my  students, 
because  they  are  private  patients. 

Heredity. — The  facts  of  nature  compel  the  physician  to  see 
that  purely  mental  and  moral  quahties  and  mental  defects  are 
transmissible  from  parent  to  child,  and  prepare  him  for  the 
great  part  that  heredity  plays  in  psychological  development 
and  in  mental  disease.     It  has  not  yet  been  proved  statistically 


CLINICAL   STUDY  OF   MENTAL  DISEASES.  3 

whether  a  man's  features  or  the  acuteness  of  his  moral  sense 
are  most  apt  to  be  transmitted  to  his  children  or  grandchildren, 
but  I  am  strongly  of  opinion  that  the  latter  will  be  found  to 
be  equally  so  with  the  former. 

Organic  Unity. — The  medico-psychological  student  finds 
that,  in  addition  to  the  influence  of  temperament,  diathesis, 
and  heredity,  the  working  of  mind  in  each  individual  is 
influenced  daily  by  other  organs  than  the  brain.  He  finds 
the  so-called  animal  and  organic  functions  and  propensities  so 
interwoven  with  the  purely  mental  functions,  such  inter- 
action and  re-action  between  them  all,  that  he  instinctively 
forms  the  conclusion  and  acts  on  it,  that  he  must  look  on  the 
whole  man — body  and  mind — from  the  point  of  view  of  an 
organism  whose  whole  needs  and  capacities  exhibit  unity  and 
solidarity  throughout.  Take,  for  instance,  the  function  of 
alimentation.  No  doubt  the  swallowing,  digestion,  and 
absorption  are  chiefly  mechanical  and  chemical  processes, 
performed  in  a  living  laboratory,  yet  he  would  be  but  a  blind 
and  narrow-sighted  observer  who  failed  to  see  the  enormous 
mental  and  moral  influence  that  the  desire  for  food,  the 
appetite  for  food,  and  the  varied  pleasures,  organic  and 
conscious,  that  suitable  food  produces.  He  would  soon  in 
his  practice  meet  with  cases  where  in  rational  men  a  badly- 
cooked  dinner,  or  certain  unsuitable  foods,  poisoned  the 
blood,  and  made  life  not  worth  having  to  themselves,  and  a 
torment  to  those  about  them.  And  a  wider  view  would 
show  that  different  kinds  of  food  affected  the  mental  develop- 
ment of  whole  races  of  men ;  while  the  want  or  poverty  of 
food  had  made  civilised  men  into  wild  beasts,  as  during  the 
French  Revolution,  or  among  shipwrecked  sailors.  The 
absolute  dependence  of  the  appetite  for  food  on  brain  and 
ganglionic  integrity  and  sound  working  is  so  often  seen  by 
physicians,  that  they  need  no  physiological  proof  that  this 
appetite  is  a  brain  function.  What  stops  the  appetite  at 
once  when  sudden  fear  or  joy  is  felt  ?  Through  what  organ 
is  it  perverted  during  pregnancy  or  in  hysteria  ? 


4  CLINICAL   STUDY   OF   MENTAL   DISEASES. 

Reproduction. — Take  a  function  still  more  nearly  affecting 
mentalisation,  that  of  the  reproduction  of  the  species.  What 
practical  student  of  mind  can  disregard  it  ?  What  physician 
can  overlook  the  part  it  plays?  How  directly  it  influences 
the  whole  affective  life  and  history  of  mankind  !  How  the 
ascetic  rehgionists  of  all  creeds,  with  ideal  a  2^riori  standards 
of  life  hefore  them,  have  striven  to  set  themselves  free  from 
its  influence  on  their  minds  and  lives  !  What  attempts  have 
been  made  to  degrade  it  into  something  almost  criminal  and 
brutish  in  one  age,  to  ignore  it  in  the  next,  and  to  ideahse  it 
in  the  next !  The  psychological  physician  must  simply  accept 
the  facts  of  physiology,  and  regard  man  as  a  whole,  mind  and 
body.  So  regarding  him,  he  is  every  day  beset  with  problems 
that  imply  consideration  of  the  reproductive  functions  of  the 
human  species,  and  their  effects,  direct  and  indirect,  on  the 
minds  of  his  patients.  And  the  sooner  he  begins  to  regard 
the  whole  matter  from  the  physiological  and  professional 
point  of  view,  just  as  the  obstetrician  does  his  work,  the 
better  for  himself  and  his  patients.  It  will  often  need  all  his 
physiological  knowledge  and  his  psychological  study,  combined 
with  his  common  sense  and  general  knowledge  of  human 
nature,  to  expiscate  the  mental  sympathies  and  aversions,  the 
reflex  and  sympathetic  irritations  and  impulses,  and  the 
paralysed  volitions  of  the  neurotic  among  his  adolescent, 
hysterical,  puerperal,  and  climacteric  patients. 

Questions  to  be  Asked. — Those  students  who  attend  my 
clinical  lectures  will  find  that  there  are  few  questions  I  shall 
so  often  ask  as  those — "  What  sort  of  man  was  this  when  he 
was  reckoned  well  in  mind  1 "  "  How  does  he  now  differ 
from  his  state  then  ? "  "  Are  his  present  mental  peculiarities 
evolutions  of  his  temperament?"  "Are  they  connected  with 
his  diathesis?"  "  Wliat  is  the  exact  nature  of  the  mental 
disturbances  present?"  "Is  the  judging,  the  feeHng,  the 
controlling,  the  resistive  powers,  the  memory,  the  attention,  or 
the  imagination  affected  ?  and  if  so,  in  what  degrees  and 
ways?"     "Is  there  general  mental  exaltation,  depression,  or 


CLINICAL   STUDY  OF   MENTAL   DISEASES.  5 

enfeeblement  present  ?  "  "  Are  the  mental  symptoms  fixed 
or  changing?"  "Is  the  sleep  function  interfered  with?" 
"  Do  those  disturbances  bear  relation  to  any  disturbance  of 
the  great  functions  of  the  body  ?  "  "  Wliat  bodily  functions 
are  disordered  along  with  the  mental  1 "  "  Was  the  onset  of 
the  mental  disease  connected  with  any  functional  evolution 
such  as  puberty,  with  any  ordinary  physiological  process  such 
as  menstruation,  or  with  any  extraordinary  physiological  cata- 
clasm  such  as  childbirth?"  "Are  any  of  the  other  great 
functions  of  the  nervous  centres,  such  as  motion  or  sensibility, 
impaired  ?  and  if  so,  whether  primarily  or  secondarily  to  the 
disordered  mentalisation  ? "  This  is  the  clinical  mode  of 
studying  mental  disease,  founded  on  a  physiological  basis.  It 
imphes  something  far  more  than  merely  classifying  the  mental 
symptoms  of  your  patients,  and  ticketing  the  various  groups 
with  a  name.  You  can  easily  imagine  the  same  mental 
symptoms  to  exist,  and,  as  a  matter  of  fact,  they  very  often 
do  exist,  in  a  girl  of  15  entering  on  puberty  and  in  a  puerperal 
woman,  but  in  the  latter  case  the  bodily  symptoms  would  be 
quite  different  from  the  former,  the  temperature  perhaps 
being  103°,  the  lochia  absent,  the  tongue  dry,  the  pulse  feeble, 
the  uterus  septic  and  irritated,  and  the  general  condition  so 
weak  that  a  few  more  steps  downward  would  lead  to  death  ; 
while  in  the  former  the  strength  would  be  good,  the  pulse 
good,  and  the  temperature  but  little  raised.  Both  cases, 
looked  at  from  the  point  of  view  of  mental  symptoms,  would 
be  called  acute  mania,  and  yet  they  would  be  quite  different 
in  etiology,  in  bodily  symptoms,  in  prognosis,  and  in  treat- 
ment. 

We  next  come  to  the  question  of  how  far  mere  temporary 
causes,  such  as  changes  in  the  blood  supply,  excesses  of  work, 
emotional  strains  of  aU  kinds,  or  reflex  irritations,  affect  the 
mental  energy  of  the  brain,  but  still  keep  witliin  a  line  that 
may  be,  and  ought  to  be,  reckoned  physiological.  If  a  man 
works  till  he  cannot  any  longer  hft  his  arm,  we  do  not  call  it 
paralysis ;  if  he  sleeps  so  soundly  afterwards  that  no  ordinary 


6  CLINICAL   STUDY   OF   MENTAL   DISEASES. 

stimuli  will  awake  liim,  we  do  not  call  it  coma :  we  place 
neither  condition  out  of  the  physiological  into  the  pathological 
state.  So,  if  a  man's  heart  is  made  glad  by  wine,  or  by 
extraordinary  good  news,  and  he  shows  many  signs  of  mental 
exaltation  unusual  in  him,  if  he  loses  blood  or  has  bad  news, 
and  is  profoundly  depressed,  we  still  call  these  states  physio- 
logical, and  do  not  count  them  pathological  mentahsation  at 
all.  A  man's  power  of  judging  and  comparing,  Ms  emotional 
reactiveness,  his  inhibitory  power,  may  all  be  so  far  paralysed 
as  to  be  in  abeyance  for  the  time,  and  yet  we  may  count  him 
free  from  mental  disease.  jSTay,  I  have  seen  two  men  in 
exactly  the  same  condition  for  the  time  being,  so  far  as 
mental  symptoms  were  concerned,  and  I  counted  the  one  sane 
and  the  other  insane.  ^Tien  the  hmits  of  the  physiological 
are  passed,  and  a  man  enters  on  a  pathological  state  of  mind, 
we  are  often  utterly  unable  to  tell  the  exact  line  where  the 
one  ends  and  the  other  begins.  As  Maudsley  says,  you 
might  as  well  attempt  to  draw  the  line  between  hght  and 
darkness. 

The  Mental  Clinician. — For  the  study  of  mental  disorders, 
while  the  general  state  of  mind  must  be  the  same  as  that  in 
wliich  we  study  ordinary  bodily  diseases,  while  it  is  essentially 
the  chnical  faculties  that  we  put  into  exercise,  yet  there  needs 
to  be  superadded  a  different  mode  of  finding  out  what  the 
morbid  symptoms  are,  more  of  comparison  of  subtle  mental 
and  moral  changes  with  health,  more  scepticism  as  to  Avhat 
the  patient  says  about  his  own  symptoms,  and  often  far  more 
strain  in  the  analysis  of  character  and  motive,  and  in  the 
effort  to  draw  out  the  patient  into  a  veracious  and  open  state 
of  mind.  The  constant  effort  to  interpret  the  chnical 
meanings  of  subtle  changes  in  your  patient's  face  and  manner, 
and  the  significance  of  what  he  says  and  how  he  says  it,  is 
wearying  ;  while  the  difiiculties  of  dehcately  leading  him 
over  the  ground  where  his  mental  deficiencies  exist  are  often 
excessively  great.  His  every  word  and  act  must  be  closely 
scrutinised,  for  they  form  part  of  the  symptoms  on   which 


CLINICAL   STUDY   OF   MENTAL   DISEASES.  7 

your  diagnosis  rests.  An  initial  difficulty  with  the  unin- 
structed  is  in  the  want  of  terms  to  express  the  mental 
symptoms.  I  have  heard  a  man  try  to  describe  the  symptoms 
of  an  ordinary  case  of  acute  dehrious  mania  to  me,  and  utterly 
fail  to  give  any  connected  idea  of  the  patient's  state.  Such 
a  description  as  this  I  have  often  got :  "  He  won't  do  any- 
thing you  tell  him.  I  can't  make  anything  of  him.  He  talks 
a  lot  of  nonsense.     He's  just  mad." 

Classification. — Though  ournomenclature  for  the  deviations 
from  normal  mentalisation  is  as  yet  unscientific  and  incomplete, 
and  must  one  of  these  days  be  revised,  yet  most  abnormalities 
are  capable  of  being  in  some  way  described  and  classified.    The 
mental  symptoms  met  with  have  been  classified,  and  this  is 
the  first  classification  of   mental   diseases  to   which   I   shall 
direct  your  attention.     It  is  largely  only  a   classification  of 
symptoms,  not  of  real  diseases,  but  those  symptoms  are  most 
important  and  stand  out  in  dignity  and  character  from  the 
ordinary   symptoms  of   other  diseases.      In  themselves,  and 
apart  from  the  cortical  disturbances  from  which  they  result, 
they  are  well  worthy  of  earnest  study  and  separate  classifica- 
tion.    Mind  is  universally  and  instinctively  recognised  to  be 
"  the   greatest   thing  in  man."     As  symptoms  they  are   far 
more  interesting  than  most  diseases,  for   they   constitute   a 
part  of  the  general  study  of  mind  and  of  human  nature.     The 
nomenclature  tliis  classification  gives  us  is  essential  for  our 
study  of  disordered  mind,  and  its  terms  have  become  current 
in  medicine,  jurisprudence,  and  general  hterature.     Pinel's 
and  Esquirol's  original  classification  of  mental  diseases  on  this 
principle  has  undergone  many  modifications  and  extensions, 
and  I,  Hke  my  predecessors,  have  introduced  some  changes. 
The  principles  on  which  it  is  founded  are,  to  take  one  example, 
that   all   the  states  of  morbid  mental  depression  and  painful 
feeling  are  classed  under  one  head,  Melancholia,  just  as  all  the 
painful  disorders  of  sensibility  are  called  Ifeuralgia.     Indeed 
the  melanchohas  bear  a  close  analogy  to  the  neuralgias.     In 
the  one  case  the  emotional  functions  of  the  brain  are  affected, 


8  CLINICAL   STUDY   OF  MENTAL  DISEASES. 

in  the  other  the  common  sensibility.  Most  cases  of  melan- 
choha  might  be  called  mental  pain,  or  Psychalgia?- 

Then  all  the  states  of  morbid  mental  exaltation  or  excitement 
without  depression  are  classed  together  and  caUed  Mania,  just 
as  the  motor  storms  and  explosions  are  called  convulsions, 
eclampsias,  epilepsies,  or  spasms.  A  typical  case  of  mania 
may  be  considered  like  a  mental  chorea  or  eclampsia.  There 
is  present  disordered,  incoherent,  involuntary,  purposeless 
mentalisation.     Mania  might  be  called  a  Psychlampsia. 

There  are  other  cases  whose  symptoms  consist  of  regularly 
alternating  mental  states,  usually  of  depression  and  exaltation, 
this  rhythmical  recurrence  of  mental  pain  and  spasm  going  on 
during  the  whole  course  of  the  disease,  and  constituting  its 
essential  distinctive  character.  I  think  a  better  name  for  this 
than  the  one  given  to  it  by  Baillarger,  who  first  described 
it,  viz.,  Folie  Circulaire,  would  be  Alternating  Insanity 
{Psychorythm).  Though  only  described  as  a  variety  of  mania 
by  him,  yet  I  think  its  characters  are  so  distinctive  as  to 
vindicate  for  it  a  special  place  in  a  complete  symptomatological 
nosology,  which  I  have  accordingly  given  it.  Its  study,  as  we 
shall  see,  leads  naturally  to  the  investigation  of  the  part  played 
by  the  laws  of  nervous  periodicity  in  mental  and  nervous 
disorders. 

The  fixed  delusional  states  without  excitement  or  depression 
come  next,  the  Monoinanias.  Just  as  we  now  separate  the 
monospasms  and  the  local  convulsions  from  the  general 
eclampsias,  I  think  it  is  better  to  place  the  cases  of  mono- 
mania by  themselves,  instead  of  calling  them,  as  some  authors 
do,  partial  mania.  Monomania  is  sometimes  analogous  to  a 
paraesthesia.  If  a  man  hears  distinct  articulate  words  which 
are  merely  the  moanings  of  the  wind  to  others,  and  if  those 
subjective  false  voices  call  him  bad  names,  he  becomes  sus- 

^  It  mi;st  be  understood  that  I  only  devised  this  nomenclature  to 
enable  students  better  to  understand  the  psychoses  by  analogy  with  the 
diseases  with  which  they  were  already  familiar,  and  for  class  purposes. 
I  have  no  wish  to  bring  it  into  general  use  in  medicine. 


CLINICAL  STUDY   OF   MENTAL   DISEASES.  9 

picious  of  the  people  about  him ;  this  may  become  a  morbid 
habit  of  his  mind,  without  any  special  excitement  or  depression, 
and  we  say  he  labours  under  monomania  of  suspicion.  This 
is  one  way  in  which  delusion  may  arise.  A  true  impression 
from  a  nerve  of  common  sensibility  may  be  misinterpreted, 
as  when  a  man  has  cancer  of  his  stomach  that  causes  him  real 
gnawing  pain,  and  he  says  he  has  rats  inside  liim  that  are  eating 
his  vitals.  It  may  help  you  to  understand  this  condition  of 
partial  insanity  better  if  you  think  of  it  as  a  Monopsychosis. 

When  the  morbid  condition  is  one  of  general  mental  enfeeMe- 
ment  it  is  called  Devientia  or  Amentia,  both  very  good  terms. 
Dementia  I  would  restrict  to  incurable  conditions  of  enfeeble- 
ment  commonly  secondary  to  other  mental  states.  Amentia 
means  enfeeblement  from  birth,  constituting  Idiocy,  or  Con- 
genital Imbecility.  The  conditions  they  represent  are  analogous 
to  the  anaesthesias,  pareses,  and  paralyses  that  result  when  the 
sensory  and  motor  centres  of  the  brain  are  respectively  diseased. 
They  might  be  called  Psychoparesis. 

The  next  on  the  hst,  I  have  placed  there  because  it  fills  up 
a  gap  that  existed  in  former  classifications  of  mental  symptoms. 
It  represents  the  outboard  negation  of  mentalisation  resulting 
from  disease,  where  the  patients  are  insensible  to  external 
influences,  will  not  speak,  where  the  faculty  of  attention 
appears  to  be  quite  gone,  and  where  they  appear  not  to  think 
or  feel  at  all,  I  can  devise  no  better  name  than  the  usual 
one  of  Stupor,  Amentia  being  already  appropriated  to  Idiocy. 
"  Psychocoma  "  would»express  this  condition. 

Inasmuch  as  physiology  has  clearly  demonstrated  the  exist- 
ence of  centres  in  the  nervous  system  that  control  other 
nervous  centres,  giving  the  name  of  inhibition  to  the  function 
of  the  former ;  and  we  find  that  there  are  certain  cases  of 
mental  disease,  where  an  analogous  function  of  the  higher 
mental  centres  seems  to  be  deranged,  where  there  are,  in  fact, 
states  of  want  of  inhibitory  mental  power  without  marked 
depression,  exaltation,  or  enfeeblement,  I  have  put  those  under 
a  special   class,  viz.,  States  of  Defective   Mental   Inhibition. 


10  CLINICAL   STUDY   OF   MENTAL   DISEASES. 

Those  miglit  "be  called,  for  the  sake  of  keeping  up  a  scientific 
correspondence  in  the  nomenclature,  Psychokinesia. 

Lastly,  there  is  a  mental  state  graphically  descrihed  hy  Dr 
Maudsley,  and  which  certainly  represents  facts  in  nature,  the 
insane  temperament  or  neurosis  insana,  or,  to  keep  up  uni- 
formity of  the  classification,  Psychoneurosis.  This  consists 
more  of  potentialities  of  psychosis,  of  extraordinary  and 
unusual  assortments  of  mental  faculties,  of  states  of  feeling 
that  are  unaccountable  and  uncommon,  and  of  courses  of 
conduct  that  seem  merely  automatic  and  incapable  of 
vohtional  regulation — all  these  tilings  being  the  result  of  a 
hereditary  neurosis  in  a  brain  whose  various  functions  and 
parts  are  unconformable,  or  whose  dynamical  constitution  is 
unstable  and  eccentric.  The  more  recent  term  Paranoia 
includes  some  of  those  cases  and  some  of  those  of  monomania. 
The  following  therefore  is  the  Symptomatological  Classification 
I  shall  use,  with  the  chief  varieties  of  each  form  : — 

1.  States  of  Mental  Depression  {Melancholia,  Psychalgia)  : — 
a.  Simple  Melancholia.  6.  Hypochondriacal  Melancholia,  c. 
Delusional  Melanchoha.  d.  Excited  Melanchoha.  e.  Resis- 
tive (obstinate)  Melancholia.  /.  Convulsive  Melanchoha.  g. 
Organic  Melanchoha.  A.  Suicidal  and  Homicidal  Melan- 
choha. 

2.  States  of  Mental  Exaltaiion  {Mania,  Psychlampsia)  : — 
a.  Simple  Mania,  h  Acute  Mania,  c.  Delusional  Mania. 
d.  Chronic  Mania,  e.  Ephemeral  Mania  {Mania  Transi- 
toria).    f.  Homicidal  Mania. 

3.  States  of  Regularly  Alternating  Mental  Conditions  {Folie 
Girculaire,  Psychorythm,  Folie  a  Double  Forme,  Circular  In- 
sanity, Periodic  Mania,  Recurrent  Mania,  Katatonia). 

4.  States  of  Fixed  and  Limited  Delusion  {Monomania,  Mono- 
psychosis) : — a.  Monomania  of  Pride  and  Grandeur,  h. 
Monomania  of  Unseen  Agency,  of  Suspicion,  of  Persecution 
and  Fear. 

5.  States  of  Mental  Enfeeblement  {Dementia  and  Amentia, 
Psychoparesis,  Congenital  Imbecility,  Idiocy) : — a.  Secondary 


CLINICAL   STUDY   OF   MENTAL   DISEASES.  11 

(Terminal)  Dementia  {following  Mania  and  Melancholia),  h. 
Primary  Enfeeblement  (Imbecility,  Idiocy,  Cretinism,  the 
result  of  deficient  Brain  Development,  or  of  Brain  Disease  in 
very  early  life),  c.  Senile  Dementia,  d.  Organic  Dementia 
(the  result  of  gross  Organic  Brain  Disease). 

6.  States  of  Mental  Stupor  (Stupor,  Psychocoma) : — a. 
Melancholic  Stupor,  "Melancholia  Attonita."  h.  Anergic 
Stupor,  "Primary  Dementia,"  "Acute  Dementia,"  "Dementia 
Attonita."  c.  Secondary  Stupor  (transitory  after  Acute 
Insanities). 

7.  States  of  Defective  Inhibition  (PsychoJcinesia,  Hyper- 
Jcinesia,  Impulsive  Insanity,  Volitional  Insanity,  Uncontrollahle 
Impulse)  : — a.  General  Impulsiveness,  h.  Epileptiform  Im- 
pulse, c.  Animal,  Sexual,  and  Organic  Impulse,  d.  Homicidal 
Impulse,  e.  Suicidal  Impulse.  /.  Destructive  Impulse,  g.  Dip- 
somania,   h.  Kleptomania,    i.  Pyromania.    k.  Moral  Insanity. 

8.  The  Insane  Diathesis  (Psych oneurosis,  Neurosis  Insana). 
All  these  varieties  of  mental  disease  find  their  origin  in  and 

flow  out  of  excesses,  defects,  and  irregularities  in  the  physio- 
logical functions  of  the  brain.  They  may  all  arise  from 
innate  morbid  tendencies  in  the  organ,  or  from  eccentric 
causes  within  or  without  the  organism.  The  brain  responds 
by  thought,  by  feeling,  by  instinctive  and  reflex  acts,  to 
almost  everything  in  the  universe  outside  it,  and  to  every 
tissue,  organ,  and  energy  within  the  organism,  and  no  two 
brains  are  alike  in  their  reactions.  If  its  constitution  is 
unsound  therefore,  or  if  its  conditions  of  energising  are  un- 
physiological,  the  causes  being  innumerably  various  without 
and  within  for  aberration  and  derangement,  it  results  that 
the  symptoms  are  almost  as  various  as  the  causes  of  mental 
disease.  More  than  of  any  other  disease,  it  may  be  said  that 
no  one  ever  saw  two  cases  precisely  alike.  This  or  any  other 
classification,  therefore,  only  represent  types  and  genera,  not 
species.  The  reactiveness  of  the  cortical  cell  diff'ers  in  every 
human  being,  just  as  his  face  differs  from  every  one  else,  and 
reactiveness  is  the  brain  quality  chiefly  affected  in  insanity. 


12  CLINICAL   STUDY   OF   MENTAL   DISEASES. 

Clinical  Classification. — Such  was  until  recently  tlie  usual 
mode  of  studying  and  classifying  mental  diseases.  It  assumes 
that  the  mental  symptoms  are  the  chief  things  ahout  those 
diseases  to  be  observed.  The  late  Dr  Skae,  follo^ving  Morel 
and  Schroeder  van  der  Kolk,  devised  and  directed  special 
attention  to  another  mode  of  looking  at  mental  disease,  which 
we  may  call  the  clinical  method.  It  endeavours  to  take 
account  of  causes,  and  of  the  relationship  the  different  varieties 
of  the  disease  have  to  the  great  physiological  periods  of  Ufe, 
and  to  the  activities  of  the  body  other  than  the  mental — in 
other  words,  it  regards  the  whole  natural  history  of  the 
disease. 

The  chief  varieties  of  this  Clinical  Classification  (which 
includes  the  pathological  varieties  of  mental  disease)  are 
the  following  : — 

1.  General  Paralysis.  2.  Paralytic  Insanity  {Organic 
Dementia).  3.  Traumatic  Insanity.  4.  Epileptic  Insanity. 
5.  Syphihtic  Insanity.  6.  Alcohohc  (and  Toxic)  Insanity.  7. 
Rheumatic  and  Choreic  Insanity.  8,  Gouty  (Podagrous) 
Insanity.  9.  Phthisical  Insanity.  10.  Uterine  and  Men- 
struational  Insanity.  11.  Ovarian  Insanity.  12.  Hysterical 
Insanity.  13.  Masturbational  Insanity.  14.  Puerperal 
Insanity.  15.  Lactational  Insanity.  16.  Insanity  of  Preg- 
nancy. 17.  Insanity  of  Puberty  and  Adolescence,  18. 
Climacteric  Insanity.     19.  Senile  Insanity. 

There  are  a  number  of  more  rare  and  less  important  cHnical 
varieties  of  insanity,  wliich  I  shall  just  allude  to,  viz.  : — 

1.  Anaemic  Insanity.  2.  Diabetic  Insanity.  3.  Insanity 
from  Bright's  Disease.  4.  The  Insanity  of  Oxaluria  and 
Phosphaturia.  5.  The  Insanity  of  Cyanosis  from  Bronchitis, 
Cardiac  Disease,  and  Asthma.  6.  Metastatic  Insanity.  7. 
Post-Febrile  Insanity.  8.  The  Mental  Concomitants  and 
Results  of  Influenza.  9.  Insanity  from  Deprivation  of  the 
Senses.  10.  The  Insanity  of  ^lyxoedema.  11.  The  Insanity 
of  Exophthalmic  Goitre.  12.  The  Delirium  of  Young 
Cluldren,     13.  The  Insanity  of  Lead  Poisoning.     14.  Post- 


CLINICAL   STUDY   OF   MENTAL   DISEASES.  13 

Connubial  Insanity.  15.  The  Pseudo-Insanity  of  Somnam- 
bulism.    16.  Insanity  following  Surgical  Operations. 

The  classification  of  the  future  will  be  one  on  a  pathological 
basis.  But  we  are  far  from  that  yet,  and  any  premature 
attempts  to  construct  such  a  classification,  not  founded  on  a 
sound  brain  physiology  and  psychology,  must  do  more  harm 
than  good.  Certain  crude  suggestions  for  classifying  mental 
disturbances  by  means  of  the  vascular  and  lymphatic  changes 
that  can  be  recognised  in  some  cases,  especially  in  acute 
insanity,  seem  to  miss  the  essential  relationship  of  those 
structures  to  the  neurine.  The  vessels  and  lymphatics  are  the 
servants  of  the  nerve  cells,  not  their  masters,  except  in  rare 
and  exceptional  cases.  The  original  stimulus  towards  vascular 
and  other  intra-cranial  abnormalities  comes  from  the  trophic 
and  vaso-motor  centres  within  the  brain  cortex.  You  might 
as  well  classify  the  men  and  women  in  a  city  through  the 
clothes  they  wear,  the  hoiises  they  dwell  in,  and  the  tools 
they  work  with. 

In  studying  mental  diseases,  one  must  constantly  refer  to  the 
general  functions  of  the  brain,  and  I  have  thought  it  might 
be  useful  to  point  out,  in  the  following  form,  the  bearings 
of  some  of  the  most  important  anatomical,  physiological, 
psychological,  and  pathological  considerations  on  that  study  : — 

There  is  in  the  brain  an  extreme  Hence  we  are  apt  to  have  many 

complexity  of  tissues,   fibres,   and  functions  and  structures   involved 

groupings,  and  an  extreme  delicacy  in  mental  diseases — motor,  sensory, 

of  structure,  these   corresponding,  vaso-motor,  and  trophic.     Localisa- 

no  doubt,  to  the  multiformity,  com-  tion  is  never   complete,  and   soli- 

plexit}?^,  and  delicacy  of  its  func-  darity  is  never  perfect, 
tious.  There  is  an  obvious  inter- 
dependence of  parts,  a  localisation 
of  structures  and  functions,  and  yet 
a  real  solidarity  of  the  whole  brain 
in  structure  and  function. 

There  is  the  most  direct  connec-  Hence  peripheral  lesions  and  dis- 

tion,  structurally  and  functionally,  ordered  functions  of  organs  cause 

of  every  organ,  of  every  tissue,  and  mental     disturbances,     and      vice 

of  every  function  with  the  brain  con-  versd.        The     mental     symptoms 

volutions,    each    being    separately  often  take  their  special  character 


14 


CLINICAL   STUDY   OF   MENTAL  DISEASES. 


"represented"  there,  and  their 
influence  is  mutual,  powerful,  and 
onstant. 

Developmeutally  and  function- 
ally one  nervous  ganglion  or  group 
of  cells  is  "  higher  "  than  another, 
and  the  higher  usually  controls  or 
stops  the  action  of  the  lower. 

Looking  at  the  brain  convolu- 
tions, their  neurons  and  granules 
differ  in  shape  and  size  in  different 
parts  of  the  organ.  They  are  placed 
in  distinct  layers,  and  arranged  in 
groups,  those  also  differing  in  dif- 
ferent regions.  They  have  been  de- 
monstrated to  be  different  in  appear- 
ance in  young  children,  in  idiots,  in 
old  persons,  and  in  many  cases  of 
insanit}^  from  what  they  are  in  a 
healthy  adult  (see  PI.  xiii.  figs.  2-6, 
and  PI.  XV.  figs.  6-10). 

There  are  some  reasons  to  suppose 
that  parts  of  the  brain  convolu- 
tions can  energise  in  different  ways, 
one  part  being  capable  of  doing  the 
work  ordinarily  done  by  another. 
Then  every  part  of  the  brain  is 
double. 

The  brain  has  a  reflex  and  auto- 
matic action.  Most  of  its  func- 
tions are  affected  by  this,  and  may 
be  excited  into  activity  or  may  be 
disturbed  in  a  reflex  manner  by  in- 
direct stimuli,  as  the  heart  is  from 
stomach  derangement.  Most  of  the 
reflex  functions  of  the  brain  may  be 
unattended  by  consciousness  ;  or 
consciousness  without  volition  may 
be  present  in  regard  to  mental  acts 
and  to  subsequent  muscular  action. 

The  study  of  the  physiological 
conditions  of  sleep,  dreaming,  and 
hypnotism,  are  most  important, 
though  as  yet  many  of  the  pheno- 
mena are  very  obscure. 


from  the  peripheral  function  dis- 
turbed. 

Hence   disorder    of   the    higher 

centres  is  far  more  important  than 
the  lower. 


Hence  we  have  a  structural  basis 
for  certain  forms  of  insanity,  and 
for  limited  mental  disturbances, 
and  therefore  a  definite  pathological 
histology  of  many  forms  of  the 
disease  may  be  confidently  looked 
for  in  the  future  (see  Pis.  xiii.  and 

XV.). 


If  this  is  so,  damage  to,  or  ex- 
haustion of,  one  portion  of  brain 
convolutions  [as  in  Goltz's  and 
Nothnagel's  experiments]  need  not 
necessarily  cause  complete  or  irre- 
trievable loss  of  mental  functions. 

In  mental  disease,  this  reflex 
function  of  the  brain  plays  a  most 
important  part.  Many  symptoms 
can  only  be  rightly  explained 
by  it.  In  many  mental  diseases 
the  brain  acts  automatically  ;  even 
suicidal  and  homicidal  impulses 
taking  place  when  volition  and 
consciousness  are  absent. 


The  psychological  facts  of  those 
conditions  should  be  kept  in  mind 
in  studying  mental  disease.  Xo 
phenomena  of  the  latter  are  more 
obscure  than  those  of  the  former. 


CLINICAL   STUDY   OF   MENTAL   DISEASES, 


15 


Consciousness  may  be  complete, 
partial,  or  abolished  in  health. 

The  brain  normally  has  necessity 
to  energise  in  some  direction  or 
other  ;  but  energising  vigorously  in 
one  direction  will  often  suspend 
energising  in  others. 

The  brain  has  fixed  limits  of 
energising  in  all  directions. 


All  sorts  of  sensations,  we  must 
keep  in  mind,  are  subjective,  and 
depend  on  consciousness.  The  real 
import  of  most  sensations,  special 
and  common,  was  originally  only 
learned  slowly  and  by  interpreta- 
tion and  experience  in  childhood. 

There  is  a  tendency  in  the  brain 
to  propagation,  diffusion,  and  ex- 
tension of  action,  normal  and  ab- 
normal, and  there  is  much  trophic 
solidarity  in  the  whole  brain,  its 
envelopes,  and  the  nerves  connected 
with  it,  quite  independently  of 
whether  the  tissues  are  cellular  or 
fibrous,  or  whether  the  function  is 
originating  or  conducting. 


Every  mental  manifestation,  nor- 
mal or  abnormal,  must  be  assumed 
to  take  place  directly  through  the 
energising  of  the  brain  convolu- 
tions. 

Mentalisation  differs  so  enor- 
mously in  degree,  form,  and 
intensity  in  different  human  beings, 
in  the  two  sexes,  in  different  races, 
in  persons   of  different  education. 


In  mental  disease  we  see  those 
conditions  from  pathological  causes. 

In  mental  diseases  we  constantly 
put  into  active  exercise  certain 
healthy  forms  of  energising  {e.g., 
walking,  enjoying  music,  &c.),  in 
order  to  diminish  other  morbid 
forms. 

Hence  the  danger  of  causing  dis- 
turbance or  paralysis  of  function  by 
coming  too  near  those  limits,  or 
overstepping  them. 

Sensations  can  be  misinterpreted, 
therefore,  in  mental  diseases,  and, 
as  a  matter  of  fact,  many  insane 
delusions  arise  in  that  way. 


This  takes  place  abnormally  in 
disordered  working  of  the  organ, 
disordered  functional  conditions 
extending  from  the  encephalic 
tissue  regulating  one  function  to 
that  regulating  others.  There  is 
a  strong  tendency  to  progressive 
pathological  propagation  of  diseased 
processes  in  the  brain  and  along  the 
nerves.  Many  forms  of  insanity 
are,  no  doubt,  explained  in  this 
way.  Usually  the  functional  pro- 
pagations, like  the  structural  de- 
generations, take  place  in  the  line 
of  physiological  function. 

Hence,  wherever  the  "origin "  of 
mental  disease  may  be,  or  whatever 
may  be  its  "causes,"  mental  or 
physical,  its  immediate  cause  and 
seat  must  be  in  the  disordered  ener- 
gising of  the  brain  convolutions. 

Hence  the  necessity  for  special 
inquiry  as  to  the  normal  mental 
power,  the  normal  mode  of  working, 
the  education,  the  temperament, 
and  the  diathesis  in  every  case  of 


16 


CLINICAL    STUDY   OF   MENTAL   DISEASES. 


and  at  different  ages,  that  any 
correct  standard  of  mental  health 
must  allow  a  large  margin  of 
psychological  difference,  apart 
altogether  from  disease. 

The  action  of  "  mind  on  mind  " 
in  healthy  brains  is  direct,  intense, 
and  most  subtle. 

The  quality,  the  power  of  energis- 
ing and  of  resistance,  the  mode  of 
working,  the  liability  to  disease, 
and  the  recuperative  power  of  the 
convolutional  brain  tissue,  are  pro- 
bably determined  more  largely  in 
any  individual  by  his  heredity 
than  by  any  other  cause.  Bad 
heredity  may  affect  the  whole  brain 
and  all  its  functions,  or  only  a 
part  of  them. 

The  chief  of  the  human  instincts, 
appetites,  and  organic  necessities 
are — 

1.  Love  of  life,  with  efforts  to 
prolong  it. 

2.  Desire  to  reproduce thespecies. 

3.  Love  of  offspring,  with  efforts 
to  nourish  and  protect  it. 

4.  Social  instincts  in  innumer- 
able forms. 

5.  Necessity  to  energise. 

6.  Appetite  for  food  and  drink. 
Some   of    these  are   periodic   in 

their  intensity  or  occurrence. 

The  chief  faculties,  looked  at 
from  the  mental  point  of  view,  are 
perception,  ideation  and  judgment, 
volition  and  mental  inhibition, 
affective  faculty  or  all  that  relates 
to  feeling  and  emotion,  memory, 
power  of  attention,  representation 
and  imagination,  association  of 
ideas,  speech,  and  the  moral 
faculties, — consciousness  being  the 
basis  of  them  all. 


mental  disease  one  has  to  study  or 
treat. 


The  same  is  the  case  when  the 
brain  is  disordered,  and  hence  in 
psychiatry  mental  therapeutics  are  a 
most  important  means  of  treatment. 

Hence  the  importance  of  a  study 
of  heredity  in  mental  disease.  In 
some  form,  direct  or  indirect,  its 
influence  is  rarely  absent  in  any 
case. 


In  every  case  of  insanity,  atten 
tion  and  inquiry  must  be  directed 
as  to  whether  any  of  these  are  im- 
paired, paralysed,  or  perverted,  or 
whether  their  normal  mode  of 
action  is  interfered  with. 


It  is  important  in  examining  a 
case  of  mental  disease  to  go  over 
these  systematically  and  test  them, 
because  they  are  affected  in  dif- 
ferent ways  and  degrees  in  different 
cases. 


CLINICAL  STUDY  OF  MENTAL  DISEASES. 


17 


The  theorj'  of  evolution,  especially 
as  applied  by  Herbert  Spencer  in 
elucidation  of  the  morals,  the  social 
practices,  the  customs,  the  beliefs, 
the  ideas,  and  the  feelings  of  man- 
kind seem  complementary  to  our 
knowledge  of  brain  physiology. 
The  studies  of  Romanes  and  others 
in  comparative  psychology  are  also 
highly  suggestive  and  instructive. 


The  studies  of  Wundt,  Ladd,  &c., 
and  the  experimental  school  of 
Physiological  Psychologists,  are 
also  valuable  attempts  to  co-relate 
mind  and  brain  function,  by  formu- 
lating some  of  the  physical  laws  and 
concomitants  of  conscious  states, 
such  as  reaction  time,  liminal 
sensory  stimulation,  &c. 

The  great  physiological  periods 
or  crises  of  life  (dentition,  puberty, 
adolescence,  the  climacteric,  and 
senility),  and  the  great  reproductive 
activities  (menstruation,  ovulation, 
coitus,  pregnancy,  childbirth,  nurs- 
ing, and  care  of  children),  bring 
into  intense  activity,  or  throw  out 
of  action  wholly  or  partially,  great 
tracts  of  convolutional  brain  tissue. 

Diseased  or  undeveloped  function 
is  usually  accompanied  by  atro- 
phied structure,  and  prolonged  dis- 
turbance of  function  by  change  of 
structure. 

The  mode  of  energising  of  nervous 

J    tissue  is  normally  spasmodic,  and 

even  explosive,  in  regard  to  certain 

functions.     This  quality  is   often 


The  doctrine  of  evolution  seems 
to  throw  light  on  many  cases  of 
congenital  and  other  mental  defects 
by  assuming  that  in  those  cases 
development  has  taken  place  in  an 
incomplete  or  irregular  manner,  or 
that  "  reversions  "  have  taken  place 
to  more  primitive  types  of  brain 
and  mind.  Hughlings  Jackson's 
application  of  a  complementary 
theory  of  "Dissolution"  to  the 
nervous  and  mental  functions,  also 
enables  us  to  comprehend  certain 
cases  of  mental  diseases  better  than 
we  could  have  done  without  the 
aid  of  such  hypotheses. 

Every  fact  that  enables  us  to 
realise  the  necessary  connection  of 
brain-working  and  mind  in  health, 
and  which  accurately  compares 
their  relations  in  different  abnormal 
conditions  with  the  normal  stan- 
dard, helps  our  knowledge  of  that 
connection  in  disease,  and  enables 
us  to  observe  the  symptoms  of  men- 
tal disease  in  a  more  scientific  way. 

Hence  these  are  very  apt  to  be 
attended  with  danger  to  the  normal 
mental  balance  when  the  convolu- 
tional tissue  is  bad  in  quality,  un- 
stable, or  badly  nourished,  or  speci- 
ally liable  to  morbid  explosions  of 
energising.  In  every  case  of  mental 
disease  the  possible  influence  of 
these  should  be  inquired  into. 

Hence  prolonged  mental  enfeeble- 
ment  is  usually  accompanied  by 
brain  atrophy  and  prolonged  mental 
disturbance  by  structural  brain 
changes. 

This  explains  in  some  degree 
the  phenomena  of  mental  explo- 
sions and  functional  defects  being 
suddenly  developed  when  the  struo- 
B 


18 


CLINICAL    STUDY   OF  MENTAL  DISEASES. 


morbidly  developed  in  badly-con- 
stituted brains.  There  is  reason  to 
suppose  that  only  comparatively 
limited  portions  of  the  brain  can  be 
.in  action  at  the  same  time,  and 
that  even  the  whole  of  the  neurine 
tissue  subserving  the  same  limited 
function  does  not  all  come  into 
activity  at  once. 

The  blood  supply  of  the  brain  is 
enormous,  and  that  of  the  grey 
matter  of  the  convolutions  five 
times  the  amount  of  the  white. 
This  grey  matter  needs,  and  uses 
up,  far  more  blood  than  any  other 
tissue  in  the  body  in  proportion  to 
its  bulk.  The  vascular  supply  of 
the  brain  is  derived  from  different 
sources.  The  whole  encephalon  is 
divided  more  or  less  into  vascular 
areas,  each  area  having  slight 
anastomoses  with  its  surrounding 
areas.  It  is  not  yet  proved,  but  it 
is  probable,  that  those  areas  are  co- 
.related  to  different  functions.  The 
whole  conditions  of  the  blood 
supply  to  the  brain  and  within  the 
head,  are  peculiar  and  different  from 
any  other  part  of  the  body  from  its 
being  in  a  shut  box  not  subjected 
to  the  pressure  of  the  atmosphere, 
except  through  the  vascular  and 
lymphatic  openings  and  foramen 
magnum,  and  from  its  peculiar 
relation  to  the  cerebro-spinal  fluid. 
The  lymphatics  are  also  peculiar 
in  the  brain,  and  this  no  doubt 
affects  its  circulation  and  nutrition. 
The  vessels  of  the  brain,  large  and 
small,  are  delicate,  having  little  sup- 
port but  the  pressure  of  a  shifting 
fluid,  and  the  cardiac  and  vascular 
pressure  and  tension  are  constantly 
varying.  It  would  seem  as  if 
mental  emotions  had  a  more  direct 


tural  cause  has  been  a  gradually 
advancing  one,  e.g.,  we  see  sudden 
mania,  or  paralysis,  or  convulsion, 
or  unconsciousness  resulting  from 
softenings,  or  sclerosis,  or  inflamma- 
tion that  have  been  going  on  gradu- 
ally foralong  time  till  theyreacheda 
certain  point  beyond  which  normal 
function  could  not  be  performed, 
-  Hence,  when  in  certain  forms  of 
mental  disease  there  is  congestion 
or  vaso-motor  dilatation  of  those 
already  crowded  capillaries,  we  have 
serious  secondary  effects  on  the 
neurine  and  its  functions.  Nothing 
is  more  common  after  death  in 
insanity  than  to  find  the  brain 
substance  divided  into  distinct  vas- 
cular  and  anaemic  areas  (Plate  lY,). 
Certain  morbid  appearances  {e.g., 
"pachymeningitis  haemorrhagica 
interna ")  are  found  within  the 
skull,  which  are  not  found  else- 
where at  all.  The  lymphatic  spaces 
are  often  .found  blocked  up  by 
debris.  Capillary  haemorrhages 
are  common  in  insanity,  and  vas- 
cular disease  is  frequent,  and  should 
always  be  looked  for,  in  those  who 
die  mentally  affected. 


CLINICAL   STUDY  OF   MENTAL  DISEASES. 


19 


and  powerful  influence  on  the 
vessels  of  the  head  than  on  those 
of  almost  any  other  part  of  the 
body,  e.g.,  as  seen  in  blushing,  &c. 
The  various  envelopes,  and  pro- 
tecting and  packing  tissues  of  the 
brain,  are  most  important  in  them- 
selves and  in  their  normal  relation- 
ship to  the  brain.  They  derive 
their  blood  supply  from  the  same 
sources. 


It  may  be  said  generally  that  in- 
flammation and  new  pathological 
formations — tubercle,  syphilis,  can- 
cer, &c. — show  a  greater  afiinity  for 
the  non-neurine  tissues  and  blood- 
vessels than  for  the  brain  itself, 
while  the  progressive  degenerations 
tend  more  to  affect  the  true  nerve 
tissue. 

Changes  in  the  nerve  cells  have 
been  clearly  demonstrated  by  Hodge, 
Mann  and  others  to  take  place  after 
exercise  and  fatigue  as  compared 
with  rested  cells. 

The  recent  investigations  of 
Golgi,  Cajal,  Andriezen  and  others 
as  to  the  relationship  of  the  cells 
to  the  fibres,  and  the  nature  of  the 
nervous  unit,  the  "  neuron,"  can- 
not fail  to  throw  light  on  the 
mental  working  of  the  brain. 

The  recent  investigations  of 
Flechsig  into  the  development  of 
"  nerve  paths  "  in  the  brain  of  the 
child  seem  to  make  more  definite 
our  ideas  of  mental  development. 


In  mental  disease  we  often  find 
more  evident  and  constant  disease 
in  the  bones,  membranes,  neuroglia-, 
and  epithelial  linings  of  the  ven- 
tricles than  in  the  brain  itself. 
When  diseased  they  affect  the 
neurine  secondarily,  or  are  affected 
by  its  diseases  (see  Plates  I.  II., 
figs.  3  and  4  ;  VI.  XIV.  and  XV., 
figs.  1  to  5. 

Hence  we  must  specially  examine 
those  non-neurine  and  vascular 
tissues,  and  we  often  find  that 
though  they  are  affected  primarily 
by  those  new  pathological  forma- 
tions, yet  the  neurine  has  suffered 
as  much,  structurally  and  function- 
ally, as  if  it  had  been  first  affected. 

This  makes  it  all  the  more  pro- 
bable that  the  exact  import  of  the 
nerve  changes  and  degenerations,  so 
clearly  shown  by  Bevan  Lewis  and 
others  in  different  forms  of  insanity^ 
will  yet  be  demonstrated. 

And  already  disturbed  and  patho- 
logical conditions  of  the  whole 
neuron  in  insanity  have  been  de- 
monstrated. 


Flechsig  has  also  shown  that  in 
insanity  his  cortical  ' '  centres  of 
associations  "  and  nerve  paths  are 
pathologically  altered. 


As  to  the  general  method  of  chnically  examining  a  patient, 
insane  or  supposed  to  be  insane,  the  folloioing  rules  may  be 
of  service : — 


W  CLINICAL   STUDY  OF  MENTAL  DISEASES. 

1.  Get  all  the  information  about  him.  you  can  beforehand, 
and  from  the  most  direct  sources,  especially  on  the  following 
points : — His  heredity,  temperament,  habits,  and  generally 
what  sort  of  man  he  was,  what  delusions  he  labours  under, 
how  he  is  changed  from  his  former  self,  whether  he  is  mor- 
bidly suspicious  and  will  resent  a  medical  examination, 
whether  he  is  suicidal  or  dangerous,  whether  his  power  of 
self-control  is  affected  and  in  what  way,  and  his  weak  points 
mentally — get,  in  fact,  a  good  concise  history  of  his  case, 
especially  noting  the  first  symptoms  and  the  general  course. 

2.  In  your  interviews  be  in  manner  natural,  frank,  honest, 
fearless,  sympathetic,  and  a  good  hstener,  assuming  outwardly 
that  your  patient  is  sane.  Do  not  be  afraid  to  lead  up  to  his 
delusions  and  mental  weak  points  after  you  have  gained  his 
confidence  and  interest.  Do  not  contradict  or  irritate  until 
you  want  to  test  his  self-control.  Do  not  deceive  him  if 
possible.  After  you  have  satisfied  yourself  he  is  ill,  try  and 
make  him  believe  it  too.  Take  time ;  few  satisfactory  first 
examinations  can  be  conducted  in  a  hurry. 

3.  Look  on  his  speech,  manner  and  appearance  as  being,  in 
themselves,  possible  symptoms  of  his  disease ;  be  all  the  time 
in  a  quiet  systematic  way,  unobserved  by  the  patient,  testing 
his  mental  faculties  (see  p.  16)  seriatim  in  your  own 
mind,  and  be  on  the  look-out  for  insane  delusions  or 
suspicions,  depression  of  mind,  exaltation,  enfeeblement, 
lethargy  and  stupor,  or  altered  f eehng  towards  relatives  and 
friends. 

4.  Xote  carefully  the  expression  of  the  face  and  eyes,  the 
articulation,  the  manner,  the  muscular  movements,  the  writing, 
if  possible,  the  nutrition  of  the  body  and  the  conformation 
of  head. 

5.  Examine  the  state  of  the  pulse  and  temperature.  !N'ever 
think  any  examination  complete  without  taking  the  tempera- 
ture. Many  patients  labouring  under  the  delirium  of  fevers 
and  inflammations  would  have  been  saved  from  being  sent 
to  asylums  had  this  been  done.     Examine  into  the  condition 


CLINICAL   STUDY  OF  MENTAL   DISEASES.  21 

of  the  tongue,  appetite,  digestion,  bowels,  and,  in  fact,  go 
over  all  the  great  bodily  functions.  Especially  find  out  about 
the  sleep — whether  he  sleeps  at  all,  what  kind  of  sleep,  and 
for  how  long,  and  whether  he  dreams,  and  of  what  character 
the  dreams  are ;  usually  the  sleep  is  "  broken  "  and  unrestful 
in  the  early  stages  of  insanity,  the  patients  dream  much,  and 
the  dreams  are  unpleasant.  Especially  examine  into  the  motor 
and  sensory  functions  of  the  brain  and  cord,  asking  about 
headaches  and  neuralgic  pains.  Always  remember  that  the 
ordinary  symptoms  of  bodily  disease  may  be  masked  by  the 
brain  condition,  so  that  lung  and  visceral  diseases,  injuries, 
&c.,  may  exist  without  any  consciousness  on  the  part  of  the 
patient,  or  any  obvious  symptom  whatever. 

6.  Remember  there  are  three  aspects  to  every  case  of  in- 
sanity— the  medical,  which  concerns  you  as  a  physician  about 
to  treat  a  patient ;  the  medico-legal,  which  concerns  you  and 
the  patient  in  regard  to  depriving  him  of  his  Hberty  and  of 
the  control  of  his  affairs,  and  affects  his  responsibility  to  the 
law;  and  the  medico-psychological,  which  includes  all  the 
mental  problems  that  arise  out  of  a  study  of  the  case. 

7.  Always  pass  before  your  minds  the  following  conditions, 
and  by  exclusion  determine  that  the  case  is  not  one  of  them, 
viz.,  drunkenness,  drugging  by  opium  or  other  narcotics, 
meningitis,  cerebritis,  brain  syphilis,  the  fevers,  sunstroke, 
traumatic  injury  to  head,  hysteria,  the  cerebral  effects  of  gross 
brain  diseases,  simple  delirium  tremens,  the  temporary  cerebral 
effect  of  moral  shock,  or  the  dehrium  that  precedes  death  in 
many  diseases  and  in  old  age.  I  have  had  cases  of  drunken- 
ness, meningitis,  cerebro-spinal  meningitis,  typhus  and  typhoid 
fevers,  hysteria,  apoplexy,  delirium  tremens,  traumatic  injury 
to  head,  and  the  dehrium  preceding  death,  sent  in  to  asylums 
under  my  care,  as  labouring  under  ordinary  insanity,  and 
have  heard  of  the  other  conditions  being  so  mistaken.  Some 
of  these  conditions  and  diseases  may,  however,  lead  to,  or 
be  associated  with,  technical  mental  disease,  and  require  treat- 
ment as  such. 


22  CLINICAL  STUDY  OF  MENTAL  DISEASES. 

8.  In  the  clinical  study  of  mental  diseases,  try  and  look  on 
all  the  abnormalities  present,  mental  and  bodily,  as  being 
symptoms  of  the  disease,  and  essential  parts  of  the  brain 
disturbance  present,  and  not  as  mere  accompaniments.  For 
instance,  in  a  case  of  puerperal  insanity,  it  is  not  merely  the 
delusions  and  mental  exaltation  that  are  the  disease,  but  the 
high  weak  pulse,  the  raised  temperature,  the  ghstening  eye, 
the  constant  muscular  motion,  the  dry  tongue,  the  uterine 
tenderness,  the  absence  of  lochia,  the  sleeplessness,  the  paralysis 
of  appetite,  are  also  symptoms  of  the  disease  in  a  true  sense, 
that  is,  they  are  all  results  or  essential  concomitants  of  the 
brain  disturbance,  of  which  the  mental  symptoms  are  the 
most  striking  features. 

9.  The  patient's  account  of  himself  is  not  always  to  be 
relied  on.  He  may  be  dying,  and  yet  in  his  consciousness 
have  no  symptom  of  it,  so  that  he  tells  you  he  never  was 
better  in  his  life  ;  his  bowels  may  have  been  moved  freely 
that  morning,  and  yet  he  tells  you  he  has  not  had  a  motion 
for  a  week  ;  he  may  not  be  able  to  write  a  line,  yet  he  says 
he  never  wrote  so  well  in  his  Hfe,  &c.  You  must,  through 
your  reasoning,  medical  examination,  and  observation,  find 
out  what  is  true  and  what  is  delusion.  I  had  once  a  case 
where  a  medical  man  certified  as  a  delusion  wliat  an  examina- 
tion would  have  shown  him  to  be  a  fact,  viz.,  that  she  said 
she  was  pregnant.  Certain  things  of  the  greatest  import  in 
a  case  of  insanity  the  patient  is  very  apt  to  deny,  such  as 
suicidal  feehngs,  masturbation,  &c. 

10.  It  may  be  needful  in  some  cases  for  the  patient's  safety, 
or  that  of  his  relations,  or  for  the  preservation  of  his  property, 
to  practise  some  amount  of  concealment  of  your  profession, 
and  of  the  object  of  your  visit.  The  man  knows  so  well  what 
a  doctor's  visit  means  that  he  will  not  see  a  doctor  if  he 
knows  liim  to  be  one,  or  he  is  so  dangerous  and  cunning  that 
risk  would  be  run  by  announcing  to  him  the  object  of  your 
visit.  But  the  public  and  the  friends  of  patients  have  often  a 
most  needless  desire  that  you  should  practise  guile  where  there 


CLINICAL  STUDY  OF  MENTAL  DISEASES.  23 

is  no  necessity  in  the  world  for.it.  As  a  general  rule,  there  is 
not  much  to  fear  from  the  insane  of  the  respectable  classes  of 
society  in  this  country.  But  cunning  and  suspicion  are 
marked  characteristics  of  many  of  those  affected  in  mind. 
.:  11.  Negative  symptoms— silence,  obstinacy,  stupidity,  &c. — • 
are  to  be  noted,  and  are  valuable  in  diagnosis  and  treatment. 

12.  Compare  mentally  the  man  as  you  see  him  with  the 
man  you  may  have  known  or  had  described  to  you. 

13.  The  chief  questions  you  ask  yourself,  and  the  main 
problems  that  you  have  to  solve,  are  the  following : — Is  the 
man  mentally  affected  or  not?  If  so,  is  he  sufficiently 
afi'ected  to  be  regarded  as  legally  insane  and  irresponsible? 
What  form  of  insanity  does  he  labour  under  ?  Can  the  brain 
disease  be  locahsed  or  its  pathological  character  determined  ? 
What  is  to  be  the  treatment  ?  What  risks  are  there  in  the 
qase,  e.g.,  of  suicide,  danger  to  others,  convulsions,  paralytic 
attacks,  exhaustion,  refusal  of  food,  or  sudden  death  ?  What 
is  the  general  prognosis?  How  long  will  it  be  before  the 
case  recovers  or  dies?  Is  home  treatment  suitable  or  safe? 
or  must  the  case  be  removed  from  home  to  the  country,  or  to 
a  hospital  for  the  insane  ?  Can  trained  reliable  attendance 
be  got  ?  What  mental  therapeutics  must  be  adopted,  cheering 
or  soothing,  diverting,  reassuring,  checking,  agreeing  with 
him,  contradicting  him,  or  avoiding  his  favourite  topics  ? 

14.  It  is  always  weU,  in  a  case  of  mental  disease,  to  make 
the  relations  or  guardians  of  the  patient  very  fully  acquainted 
with  the  risks  of  the  case,  to  keep  them  hopeful  if  there  is 
any  hope,  to  give  the,  patient  the  benefit  of  all  doubts,  to 
guard  yourself  in  prognosis,  remembering  that  our  knowledge 
of  mental  disease  is  imperfect,  that  the  most  experienced  of 
us  are  deceived  oftentimes,  and  that  there  are  few  rules  in 
regard  to  brain  disorders  to  which  there  are  not  exceptions, 
to  take  no  more  responsibihty  about  sending  a  patient  to  an 
asylum,  for  instance,  than  fairly  can  be  laid  on  a  medical 
man,  making  the  relatives  take  their  proper  share.  It  is,  as 
a  general  rule,  better  not  to  be  too  explicit  about  the  time  it 


24  CLINICAL   STUDY  OF  MENTAL  DISEASES. 

may  take  a  patient  to  recover.  If  you  undertake  the  treat- 
ment at  home,  or  in  a  private  house,  only  do  so  on  the 
understanding  that  the  nurses  or  attendants  are  under  your 
exclusive  orders.  11  you  have  to  sign  a  certificate  of  insanity 
for  placing  a  patient  in  an  asylum,  or  taking  the  management 
of  his  affairs  out  of  his  hands,  rememher  there  is  often  a 
legal  risk  to  yourself  from  the  patient  hringing  an  action 
against  you,  a  risk  that  in  some  rare  cases  it  is  well  to  avoid 
by  even  getting  a  letter  of  indemnification  from  a  relation 
before  you  sign  it. 

15.  In  regard  to  the  question  of  home  or  asylum  treatment, 
it  depends  on  many  other  things  as  well  as  the  patient's 
condition.  His  means  are  the  fijst  of  these.  Home  or 
private  house  treatment  of  a  case  of  mental  disease  is  mostly 
expensive,  from  the  skilled  attendance  needed.  In  the  midst 
of  a  city,  home  treatment  of  almost  any  case  is  most  difficult. 
Home  treatment  is  often  impossible  or  hurtful  from  the 
associations  and  surroundings  aggravating  the  disease.  If 
there  is  a  very  intense  suicidal  tendency,  the  risks  are  much 
greater  in  a  private  house.  If  there  is  a  noise,  maniacal 
excitement,  or  constant  muscular  motion,  a  private  house  is 
seldom  a  proper  place  for  long.  In  a  good  hospital  for 
the  insane,  most  of  the  means  of  treatment,  safety,  skilled 
attendance,  exercise,  a  properly  regulated  mode  of  life,  the 
administration  of  food  and  medicines,  can  no  doubt  be  best 
attained,  but  then  there  are  the  counterbalancing  disadvan- 
tages of  the  harm  to  the  patient's  prospects  from  the  cruel 
popular  prejudices  about  asylums,  and  the  patient's  o"vvn 
feelings  about  it  afterwards.  If  you  can  treat  a  case  out 
of  an  asylum,  and  he  recovers  satisfactorily,  it  is  better  for 
you  and  him. 


LECTURE  11. 

STATES  OE  MENTAL  DEPRESSION— MELAI^- 
CHOLIA  {PSYCHALGIA). 

TTearest  Mental  health,  seen  at  beginning  of  nearly  all  kinds  of  Insanity 
— Physiological  capacity  of  feeling — Physiological  emotional  de- 
pression— Melancholic  phases  of  existence  in  all  Men— The  Melan- 
cholic variety  of  the  nervous  temperament  and  diathesis — Influence 
of  Heredity — Crises  of  life — Melancholia  is  pathologically  brain 
antemia,  vrant  of  trophic  power,  and  of  nutrition,  causing  in  certain 
persons  dynamic  disturbance — First  Symptoms:  Loss  of  sense  of 
•svell-being,  of  conscious  enjoyment  of  auytliing,  of  volitional  power, 
of  spontaneity,  paralysis  of  feeling — Afterwards  :  Delusions,  loss  of 
self-control,  intense  mental  pain,  emotional  depression,  psychical 
neuralgia,  restlessness,  excitement,  suicidal  or  homicidal  feelings 
and  acts — Bodily  Symptoms :  Headaches,  neuralgias,  sleeplessness, 
falling  off  in  flesh  and  colour,  costiveness,  indigestion,  paralysis  of 
food-appetite,  facial  and  eye  expression,  attitudes  and  gestures  and 
postures,  skin  dry,  sinking  and  pain  in  epigastrium.  First  origin  of 
Melancholia  may  be  central  or  peripheral  ;  perverted  sensations 
from  disease  in  organs  ;  how  Melancholic  delusions  arise  ;  power 
of  morbid  attention  on  functions  and  organs.  No  distinct  line 
between  the  Sane  and  Insane  Melancholy — Simple  M.  :  "Low 
Spirits,"  want  of  affection,  want  of  interest  in  and  enjoyment  of 
life ;  fancies,  whims,  with  impairment  of  reasoning  power  ;  not 
much  body  wasting  ;  sometimes  goes  no  farther ;  often  is  prelude 
to  severe  varieties,  or  to  other  forms  of  insanity ;  condition  may  come 
and  go,  and  depend  on  slight  causes — Hypocliondriacal  M.  : 
Patient's  depressed  feelings  centre  round  himself,  and  his  delusions 
are  about  his  bodily  organs  and  functions  ;  fancies  innumerable  in 
kind  and  variety ;  seldom  very  suicidal ;  differences  between  the  sane 
and  the  insane  Hypochondriac  ;  the  one  talks  only,  the  other  acts 
and  has  lost  his  inhibitory  power — Delusional  M.  :  Delusions  from 
beginning  the  most  prominent  symptoms  ;  such  delusions  assigned 
bj'^  relatives  as  the  "cause";  "Visceral"  cases,  where  delusions 
refer  to  the  stomach  and  bowels  and  internal  organs  often  depend 


26  STATES  OF   MENTAL  DEPRESSION. 

on  organic  or  aggravated  functional  causes  ;  prognosis  in  worst  class 
of  cases  bad,  as  in  all  "  fixed  delusions  "  ;  examples  of  melancholic 
delusions. 

All  the  states  of  morHdly  depressed  feeling,  or,  as  more 
commonly  expressed,  of  mental  depression,  are  comprised 
under  the  term  Melanchoha.  Like  the  other  symptomato- 
logical  varieties  of  mental  disease,  melanchoha  does  not 
admit  of  an  absolutely  precise  definition.  In  every  case 
there  must  be  mental  pain,  but  then  mental  pain  does  not 
alone  constitute  ■p.elanchoHa.  As  man's  experience  goes  in 
the  world  at  present,  mental  pain  scarcely  imphes  the  idea 
of  disease  at  all.  The  causes  and  occasions  of  mental  pain 
from  within  and  without  are  so  common,  as  most  men  are 
now  constituted  and  situated,  that  its  presence  is  the  rule 
with  many,  and  its  entire  absence  the  exception  with  most. 
To  constitute  melanchoha  there  must  be  disorder  of  brain 
function.  A  man's  finger  is  squeezed  in  a  vice,  and  he  feels 
the  most  intense  pain,  but  we  do  not  call  that  neuralgia. 
He  loses  a  child  or  a  fortune,  and  feels  intense  mental  pain, 
but  we  do  not  call  it  melancholia,  because  there  is  no  disease. 
All  mental  brain  reactions,  within  certain  hmits,  in  obedience 
to  adequate  causes  are  simply  the  exercise  of  physiological 
function,  but  when  the  reaction  is  quite  out  of  proportion 
to  the  cause,  or  when  the  exercise  of  the  activity  of  the 
brain  induces  mental  pain  of  a  certain  intensity,  duration,  or 
kind"  without  any  outside  cause,  then  we  conclude  that  the 
mental  portion  of  the  organ  is  disordered,  and  we  say  the 
patient  suffers  from  melanchoha.  There  may  be  in  the  case 
certain  excitants  called  causes — mental,  moral,  or  physical. 
The  man  may  have  committed  crimes,  or  he  may  have 
indigestion,  or  a  badly  acting  hver,  or  he  may  be  very 
ansemic,  and  all  these  things  may  cause  mental  pain  and 
depression  in  a  healthy  brain,  but  they  will  not  cause  them 
in  that  amount  and  kind  to  constitute  melancholia  tiU  his 
brain  convolutions  have  taken  on  a  disordered  action — until 
their  dynamical  state  is  that  of  disease,  not  that  of  health. 


STATES   OF   MENTAL   DEPEESSION.  27 

If  a  man's  heart  is  depressed  in  its  action  from  a  fright,  w6 
do  not  give  this  a  name  implying  disease,  unless  the  depression 
goes  on  long  after  the  cause  has  ceased  to  act.  This  illustrates, 
too,  the  weak  points  of  the  methods  of  classifying  mental 
diseases  from  mental  symptoms  alone.  It  is  as  if  in  cardiac 
diseases  we  should  classify  them  as  syncopes,  palpitations, 
and  anginas.  Therefore,  we  must  always  keep  in  mind, 
in  using  such  terms  as  melancholia,  that  the  mental  symptoms 
are  not  the  disease  ;  we  must  always  consciously  refer  those 
symptoms  to  the  hrain  convolutions  in  the  diagnosis  and 
treatment  of  mental  diseases,  wliich  are  simply  brain  disorders 
of  different  kinds  in  wliich  the  mental  symptoms  predominate. 
In  assigning  causes,  we  may  say  that  peripheral  irritations, 
and  moral  and  mental  shocks  have  caused  the  disease;  but 
we  must  clearly  keep  in  mind  that  the  mental  symptoms  of 
the  disease  are  the  result  of  the  disordered  working  of  the 
encephahc  tissue.  If  that  remains  sound  in  structure  and 
working,  no  amount  of  irritation  or  moral  shock  will  cause 
any  real  mental  disease. 

States  of  mental  depression  are,  in  some  of  their  forms,  of 
all  mental  diseases  those  that  are  nearest  mental  health.  They 
shade  off  by  imperceptible  degrees  into  mere  physiological 
conditions  of  mind  and  brain.  To  be  able  to  feel  bodily 
pain  implies  an  encephahc  tissue  for  the  purpose.  To  be 
very  sensitive  to  pain  imphes  that  the  tissue  is  acutely 
receptive  of  impressions.  In  regard  to  mental  pain  there 
can  be  no  doubt  that  the  healthy  physiological  condition 
is  one  between  extreme  callousness  to  impressions  and  extreme 
sensitiveness.  A  man  in  robust  health,  well  exercised,  does 
not  feel  pain  nearly  so  acutely,  and  bears  it  better  than  when 
he  is  weak  and  run  down.  Those  principles  apply  equally 
to  the  feeling  and  the  bearing  of  mental  pain.  To  experience 
emotion  at  all — to  feet — implies  an  encephalic  structure  for 
tliis  purpose.  The  most  casual  study  of  the  affective  capacity 
in  luiman  beings  shows  us  that  it  differs  enormously  in 
different  persons.      One  man  will  lose  his  children  or  his 


28  STATES  OF  MENTAL  DEPRESSION. 

fortune,  or  see  the  most  terrible  sights,  and  he  will  not  feel 
keenly  at  all,  because  his  brain  convolutions  that  subserve 
feehng  are  not  in  their  essential  nature  very  receptive  and 
sensitive.  Another  person  vsdll  be  thrown  into  very  great 
grief,  and  feel  acute  agony,  at  the  loss  of  a  favourite  dog. 
I  had  a  lady  patient  once,  A.  A.,  who  would  be  for  days 
depressed,  and  suifer  mentally,  if  a  friend  did  not  receive 
her  as  cordially  as  usual  any  day.  She  suffered  mental 
torture  if  a  relative  spoke  sharply  to  her,  and  she  was 
once  absolutely  paralysed  in  feeling  and  volition  by  the  death 
of  a  sister.  She  had  several  attacks  of  mild  melanchoha 
produced  by  most  inadequate  causes,  from  aU  of  which  she 
recovered  quickly  and  completely.  There  can  be  no  doubt 
whatever  that  the  finer  moulds  of  brain  are  mostly  very 
sensitive,  and  the  poetic,  emotional,  and  sympathetic  natures 
have  always  been  subject  to  states  of  painful  depression  of 
mind  at  the  critical  periods  of  life,  and  when  the  physical 
vigour  was  below  par.  Half  the  poets  and  men  of  Hterary 
genius  give  ample  proof  in  their  writings  and  in  the  characters 
they  have  created  or  founded  on  their  own  experience,  that 
they  suffered  at  times  intense  mental  pain.  Goethe  clearly 
looked  on  a  period  of  melancholy  as  one  phase  in  the  develop- 
ment of  genius.  The  hves  and  writings  of  Goethe,  Schiller, 
Carlyle,  Cowper,  Byron,  John  Stuart  Mill,  Hume,  and  George 
EHot  show  that  they  all  had  periods  in  their  Hves  when  they 
suffered  intense  mental  pain,  and  at  least  one  of  them  did 
actually  pass  the  undefined  borderland  that  separates  physio- 
logical mental  depression  from  pathological  melanchoha.  To 
feel  intense  mental  pain  is  mostly  the  necessary  accompani- 
ment of  the  capacity  to  feel  intense  joy.  The  brain  quahties 
that  give  intensity  to  the  one  give  also  intensity  to  the 
other. 

We  must  take  into  consideration  in  every  case  not  only 
the  sensitiveness  and  the  receptivity,  but  also  the  power  of 
bearing  pain^the  inhibitory  power  against  the  effects  of 
pain.     Some  brains  possess  great  sensitiveness  and  also  great 


STATES  OF  MENTAL  DEPKESSION.  29 

power  of  inhibition.  Those  are  the  strong  and  stable  brains. 
But  when  a  brain  is  sensitive,  and  has  Httle  inhibitory  power, 
tliis  combination  is  a  source  of  weakness  and  of  disease. 

There  is  a  morbid  brain  constitution  which  predisposes  to 
mental  pain,  but  that  does  not  readily  feel  intense  pleasure, 
and  this  is  common  enough  among  common  men.  It  does 
not  imply  genius  or  strength  in  any  way,  and  has  no  com- 
pensating advantages  to  its  possessors.  Persons  with  this 
tendency  are  of  the  nervous  variety  of  the  melanchohc 
temperament,  or  perhaps,  more  properly  speaking,  have  the 
melanchohc  temperament  and  the  nervous  diathesis.  They 
are  liable  to  lose  their  sense  of  well-being  from  slight  causes 
from  within  and  without  them.  Their  surplus  stock  of 
animal  spirits  and  vis  nervosa  is  soon  exhausted.  They 
want  emotional  balance  and  resistive  power.  They  are  very 
often  persons  with  strong  unreasoning  likes  and  dishkes, 
who  are  swayed  by  their  instincts,  which  they  cannot  correct 
and  guide  by  their  reasoning  power.  They  are  often  morbidly 
introspective  and  gloomily  imaginative,  having  a  faculty  for 
finding  out  and  exclusively  looking  at  the  dark  side  of 
everytliing,  and  are  very  often  irritable.  Bodily,  they  do 
not  lay  on  fat  at  the  ages  when  fat  is  physiological;  their 
digestion  is  not  their  strong  point;  when  tired  they  are 
sleepless. 

Heredity. — Such  a  brain  constitution  is  markedly  hereditary, 
andj  I  think,  is  very  apt  to  be  derived  in  the  male  sex  from 
the  mother,  and  in  the  female  sex  from  the  father,  in  about 
70  per  cent,  of  the  cases.  It  strongly  predisposes  to  attacks 
of  melancholia  as  well  as  to  attacks  of  mental  depression 
in  what  may  be  called  a  physiological  form  after  many 
bodily  diseases.  In  such  persons,  fevers,  lung  affections, 
and  cardiac  troubles  are  apt  to  be  accompanied  and  to  be 
followed  during  convalescence  by  mental  depression.  This 
is  a  serious  comphcation  in  those  circumstances,  for  it  retards 
recovery  and  tends  towards  relapses.  It  is,  no  doubt,  another 
expression  of  that  lack  of  trophic  and  recuperative  energy 


30  STATES  OF  MENTAL   DEPEESSION. 

of  tlie  brain  wldch.  "we  sliall  see  is  so  marked  a  cliaracteristic 
of  melancholia.  The  great  physiological  crises  of  life  — 
teething,  puberty,  adolescence,  the  chmacteric,  senility,  preg- 
nancy, childbirth,  and  lactation — are  apt  to  be  comphcated 
by  attacks  of  the  neuroses  in  such  persons ;  loss  of  blood,' 
over-work,  want  of  sleep,  over-anxiety,  and  menstruation 
are  also  commonly  accompanied  by  depression  of  spirits. 
Children  of  this  brain  constitution  often  exhibit  a  kind  of 
child-melancholy  at  a  very  early  period.  I  have  known  such 
a  child  at  five  years  of  age  become  intensely  depressed,  cry, 
and  moan  for  hours,  because  it  was  afraid  of  the  "hell" 
which  its  mother — of  the  same  temperament — ^had  described 
as  being  the  portion  of  bad  boys  who  tore  their  pinafores, 
sinned  against  God,  and  did  not  obey  their  mammas.  Pre- 
cocity, over-sensitiveness,  unhealthy  strictness  in  morals  and 
religion — for  a  child — a  too  vivid  imagination,  want  of  courage, 
tliinness,  and  a  craving  for  animal  food,  are  characteristic  of 
such  children. 

MelancJioly  v.  Melancholia. — It  is  very  difficult  to  draw  a 
line  of  definition  between  mere  "  lowness  of  spirits,"  ordinary 
"depression  of  mind,"  popular  "melancholy"  or  "hypo- 
chondria," and  the  pathological  melanchoHa.  They  shade  off 
into  each  other  by  fine  degrees  ;  and  yet  it  is  most  important 
to  make  a  distinction.  The  general  public,  who  are  very 
fond  of  hearing  professional  gossip  in  regard  to  medico- 
psychological  problems,  and  of  retailing  as  gospel  the  illogical 
travesties  and  popularised  versions  of  such  problems  which 
some  professional  men  retail,  have  an  idea  that  those  who 
have  studied  the  subject  most  deeply  have  come  to  the 
conclusion  that  "  all  men  are  mad  "  ;  and  this  because  we  say 
.that  no  man  but  has  his  weak  points  of  mind,  and  few  men 
but  are  subject  to  mental  depression  or  excitement,  or  to  lose 
their  self-control  at  times.  Such  a  popular  belief  does  harm, 
because  it  is  utterly  opposed  to  fact,  and  tends  towards 
confusion  and  misconception  in  regard  to  a  physician's  most 
serious   problems.      It    is    necessary,    therefore,    to   attempt 


STATES   OF  MENTAL  DEPRESSION.  31 

definitions,   even   though    they   may   not    cover   the   whole 
ground. 

Definition. — Mere  melancholy  might  be  defined  as  a  sense 
of  ill-being,  and  a  feehng  of  mental  pain  with  no  real  per- 
version of  the  normal  reasoning  power,  no  morbid  loss  of 
self-control,  no  uncontrollable  impulses  towards  suicide,  the 
power  of  working  not  being  destroyed,  and  the  ordinary 
interests  of  Hfe  being  lessened,  not  abolished. 

Melanchoha  might  be  defined  as  mental  pain,  emotional 
depression,  and  sense  of  ill-being,  usually  more  intense  than 
in  melancholy,  with  loss  of  self-control,  or  insane  delusions, 
or  uncontrollable  impulses  towards  suicide,  with  no  proper 
capacity  left  to  follow  ordinary  avocations,  with  most  of  the 
ordinary  interests  of  Hfe  destroyed,  and  commonly  with 
marked  bodily  symptoms. 

Typical  cases  exhibiting  these  two  conditions  are  totally 
different  and  distinguishable,  and  the  only  excuses  for  con- 
founding them  are  that  they  shade  oif  into  each  other,  that 
we  have  no  absolutely  definite  scientific  test  to  distinguish 
them,  that  they  are  both  in  many  cases  the  outcome  of  the 
same  temperament  and  diathesis,  and  that  they  both  have 
something  of  the  same  nature,  both  psychologically  and 
physiologically.  A  typical  case  of  melancholia,  as  we  shall 
see,  runs  a  somewhat  definite  course,  Uke  a  fever,  and  has 
often  all  the  characters  of  an  acute  disease,  in  this  being  to 
the  physician  unlike  a  mere  feeling  of  melancholy. 

Frequency. — Though,  in  the  statistics  of  asylums,  melan- 
choha does  not  appear  to  be  the  most  frequent  of  the  varieties 
of  mental  disease  (see  Plate  V.),  yet  I  think  that  if  statistics 
of  the  real  frequency  of  this  disease  in  all  its  forms,  mild  and 
severe,  could  be  got,  it  would  be  found  that  it  is  much  the 
most  common  form.  In  its  milder  varieties  it  is  a  manage- 
able disease  at  home,  in  this  contrasting  strongly  with  most 
cases  of  mania.  For  this  reason  many  cases  are  treated  at 
home  and  not  sent  to  asylums. 

As  a  general  rule,  one  has  less  difficulty  in  the  examination 


32  STATES   OF  MENTAL  DEPEESSION. 

of  a  case  of  melancholia  than  of  any  other  kind  of  insanity. 
The  "whole  process  of  ascertaining  the  symptoms  that  are 
present  is  more  hke  that  in  any  bodily  disease.  The  patient 
is  usually  conscious  that  there  is  something  wrong  with  him, 
which  is  not  the  case  in  most  forms  of  insanity.  It  is,  in 
fact,  the  sanest  kind  of  insanity.  He  can  often  describe 
many  of  his  symptoms.  Many  of  his  subjective  sensations 
are  rehable,  and  are  very  valuable  in  diagnosis  and  treatment. 
The  diagnosis  is  not  all  a  process  of  deduction  from  speech 
and  conduct,  and  from  objective  signs.  The  patient  will  tell 
you  in  the  first  place,  very  hkely,  that  he  is  ill,  very  unhappy 
and  feels  mental  depression.  In  most  cases  melanchohc 
patients  assign  as  causes  of  their  misery  what  are  not  its 
causes  at  all.  Here  it  is  where  their  insane  delusions,  their 
false  ungrounded  behefs,  come  in.  I  have  analysed  the 
"  causes  "  assigned  by  melanchoHcs  that  I  have  had  under 
my  care  during  the  past  seven  years  for  their  own  depression, 
and  I  find  them  to  be  wrong  in  most  of  the  cases.  As  to 
the  evolutional  and  purely  psychological  aspects  of  morbid 
conditions  of  depression,  or  of  any  other  morbid  mental 
conditions,  I  do  not  consider  a  clinical  work  like  this  to  be 
the  proper  field  for  their  discussion,  but  any  one  interested 
in  this  view  of  the  subject,  I  would  refer  to  Dr  Bevan  Lewis's 
text-book,^  where  they  will  find  it  profoundly  and  originally 
treated.  He  makes  an  earnest  attempt  to  apply  the  doctrines 
of  Spencer  and  the  latest  knowledge  of  brain,  physiology  to 
elucidate  the  facts  of  melanchoha,  bringing  in  Hughlings 
Jackson's  theories  of  "  dissolution  "  and  "  difi'erent  levels  " 
of  cerebral  function.  He  starts  with  the  thesis  that  in 
melanchoha  "  object-consciousness "  is  morbidly  lowered, 
whUe  "  subject-consciousness "  is  exaggerated,  that  there  is 
failure  in  the  "  muscular  element  of  thought,"  restricted 
voHtion  in  consequence,  going  on  to  "failure  of  personal 
identity."  No  summary  could  do  justice  to  his  views. 
Varieties. — ]\Ielanchoha  occurs  in  many  forms,  with  very 
^  Text-Book  of  Mental  Diseases,  by  W.  Bevan  Lewis,  vide  pp.  115-136. 


STATES   OF   MENTAL   DEPRESSION.  33 

various  psycliological  and  clinical  symptoms.  The  following 
are,  I  tliink,  the  most  common  varieties,  and  I  think  the 
study  of  the  disease  will  be  made  easier,  and  its  treatment 
become  more  intelHgible,  by  considering  those  varieties 
seriatim,  viz.  : — 

a.  Simple  melanchoHa. 
_  h.  Hypochondriacal  melancholia. 

c.  Delusional  melancholia. 

d.  Excited  (motor)  melanchoHa. 

e.  Resistive  (obstinate)  melanchoHa. 

/.  Epileptiform  (convulsive)  melancholia. 

g.  Organic  (coarse  brain  disease)  melanchoHa. 

h.  Suicidal  and  homicidal  melanchoHa. 

It  must  be  clearly  understood  that  those  are  not  distinct 
forms  of  disease.  Many  cases  combine  the  characteristic 
symptoms  of  more  than  one  of  those  varieties.  I^"othing  is 
more  common  than  for  a  case  to  be  delusional,  excited,  and 
suicidal.  It  is  also  common  for  a  case  to  change  in  its 
character  as  it  goes  on,  e.g.,  a  simple  case  to  become  delusional 
or  suicidal. 

Simple  Melancholia. — The  best  way  to  begin  the  study  of 
melanchoHa  is  to  take  a  case  of  what  may  be  called  simple 
melanchoHa,  that  is,  one  that  is  both  mild  and  uncompH- 
cated,  and  where  the  affective  depression  and  pain  are  far 
more  marked  than  the  intellectual  or  volitional  aberrations. 
Such  cases  are  very  common,  and  most  of  them  are  never 
sent  to  asylums  or  come  under  the  notice  of  specialists ; 
indeed,  many  of  them  never  come  under  the  notice  of  any 
doctor  at  all,  for  it  is  characteristic  of  some  of  them  that  they 
have  a  great  disincHnation  to  consult  our  profession.  Such 
a  case  as  the  following  is  a  good  example  of  its  mildest  form  : — 

A.  B.,  a  gentleman  of  60,  of  a  neurotic  but  not  insane 
stock,  had  inherited  from  his  mother  a  neurotic  diathesis 
and  a  melanchoHc  temperament,  and  was  of  a  sensitive, 
vivacious,  sympathetic  disposition,  and  very  studious  habits. 
He  had  kept  his  brain  at  too  full  pressure  nearly  all  his  life 


34  STATES   OF   MENTAL  DEPRESSION. 

by  his  ambition  and  volitional  force.  This  want  of  adjust- 
ment I  count  as  really  an  imperfection  of  brain  constitution, 
where  the  inhibitory  or  voHtional  power  is  so  great  as  to  be 
able  to  force  the  rest  of  the  brain  to  work  or  suffer  longer 
than  its  innate  trophic  and  dynamic  power  would  safely 
allow.  In  a  perfectly  ordered  brain  the  fatigue  of  exhausted 
energising  should  be  so  'absolute  as  to  compel  rest.  There 
should  be  no  power  in  a  higher  centre  to  compel  a  lower 
centre  to  do  more  than  it  is  fitted  for.  Yet  we  know  that 
this  is  commonly  counted  a  great  power  for  a  man  to  possess 
— to  be  able  to  work,  or  think,  or  feel,  or  wake,  or  walk,  not 
according  to  his  innate  capacity  for  these  things,  but  according 
to  his  wish  or  the  imagined  necessity  of  the  occasion.  Carlyle 
once  wrote  to  a  friend  that  like  his  father  he  "  could  gar 
(compel)  himself  to  work  when  utterly  disinclined  to  do  so." 
It  is  a  dangerous  power  for  those  of  a  neurotic  inheritance. 
All  went  on  well  till  A.  B.  was  about  50,  when,  after  a  big 
piece  of  intellectual  work,  he  began  to  feel  that  he  was 
always  tired,  he  had  a  jaded  feeling,  his  work,  instead  of 
being  a  pleasure,  became  a  conscious  toil, — indeed,  he  seemed 
capable  of  feeling  no  joy  in  life  any  more.  It  did  not  quite 
amount  to  a  sense  of  ill-being,  but  that  evidence  and  crown  of 
the  perfect  working  of  every  organ,  the  undefinable  but  very 
real  feehng  of  conscious  well-being,  had  left  him.  The 
common  pleasures  of  life,  the  society  of  his  wife  and  children 
and  friends,  were  no  longer  delightful, — indeed,  intercourse 
with  his  friends  by  speech  or  letter  was  distinctly  wearisome, 
and  he  avoided  it.  His  courage  was  manifestly  lessened,  and 
he  was  irritable  with  his  children,  an  unusual  thing  with  him. 
It  seemed  to  him  as  if  his  wife  and  children  were  less 
consciously  dear  to  him,  and  this  alarmed  him  and  made  liim 
ashamed.  He  had  a  feeling  as  if  he  had  done  sometliing 
wrong  to  cause  this — that  it  was  a  wrong  to  them  in  itself, 
and  must  be  a  judgment  on  him  for  some  sin.  His  favourite 
authors  and  poets  seemed  to  have  lost  much  of  their  charm. 
His  rehgious  duties  brought  little  comfort.     His  appetite  was 


STATES   OF   MENTAL   DEPRESSION.  35 

dulled  j  food  and  drinks  did  not  tempt  him,  and  after  a  meal 
he  was  uncomfortable.  His  sexual  desire  was  much  lessened. 
Some  of  his  instincts  and  propensities  seemed  to  be  altered. 
His  bowels  were  costive ;  his  skin  seemed  to  be  harsher  and 
drier  than  normal ;  he  had  not  the  same  f  eehng  of  reaction 
after  cold  bathing ;  he  could  not  sleep  soundly  all  the  night 
through,  and  awoke  unrefreshed;  he  was  losing  weight  a 
httle. 

But  all  this  time  he  was  not  very  thin  or  weak,  and  he 
could  appear  in  public  or  to  his  friends  just  as  usual.  He 
had  the  power  to  conceal  all  his  symptoms  from  those  to 
whom  he  did  not  want  them  known.  There  were  certain 
curious  features,  too,  in  his  case.  He  was  always  worst  in 
the  morning, — most  persons  with  any  sort  of  mental  pain 
are, — but  if  he  would  set  himself  to  write  a  letter,  or  took  a 
brisk  short  walk  in  the  sunshine,  or  took  a  cup  of  hot  coffee, 
he  would  feel  better  and  happier.  In  the  evenings,  too,  he 
would  often,  in  bright  light,  after  a  good  dinner  with  a  glass 
or  two  of  wine,  and  in  the  society  of  friends,  be  quite  himself 
again,  and  feel  almost  gay  for  a  time.  He  stopped  work, 
travelled  and  rested,  and  was  well  in  three  months.  Since 
then  he  has  had  several  such  attacks,  some  of  them  more 
severe,  during  which  the  mental  pain  was  more  positive  and 
intense,  the  conscious  mental  prostration  greater,  and  the 
paralysis  of  volitional  energy  more  complete,  so  that  at  times 
he  could  not  possibly  see  his  friends  or  put  on  before  them 
any  appeara,nce  of  cheerfulness.  At  those  times  the 
beginnings  of  delusions  showed  themselves.  He  believed, 
and  could  not  correct  the  false  belief  by  reasoning,  that  he 
was  lost  and  his  prospects  ruined,  and  that  his  life  had  been 
wasted  and  a  failure,  and  that  he  had  not  done  his  duty  by 
his  profession,  or  his  wife,  or  his  children.  At  those  times, 
too,  his  intellectual  processes  would  be  slow  and  torpid,  his 
power  of  attention  weakened,  and  the  arrival  at  any  con- 
clusion impossible  to  him  from  any  data  whatever.  When 
he   consulted   me  in   one   of   those   attacks  I  recommended 


36  STATES   OF  MENTAL   DEPEESSION. 

absolute  rest,  a  sea  voyage, — "wliicli  I  would  not  have  done 
had  he  been  in  the  least  suicidal, — almost  no  company,  plenty 
of  easily  digested  but  fattening  diet,  some  good  claret,  and 
animal  food  only  once  a  day,  I  told  him  he  might  live  on 
bread,  butter,  milk,  eggs,  fish,  fruit,  and  fresh  vegetables  if 
they  agreed  with  him  and  he  felt  that  they  digested  well. 
A  tonic  and  aid  to  digestion,  in  the  shape  of  quinine  and 
nitro-muriatic  acid,  was  all  the  medicine  I  gave  him.  I  did 
not  think  he  needed  stimulating  nerve  tonics,  and  warned 
him  against  opium,  which  some  one  had  recommended,  as 
against  his  worst  enemy.  I  told  him  to  Hve  out  in  the  fresh 
air,  as  being  nature's  great  sleep-producer,  appetiser,  and 
tonic.  I  counselled  him  against  any  expenditure  of  nerve 
energy  whatsoever,  either  in  seeing  company,  travelling  too 
fast,  walking  or  talking, — in  short,  he  was  to  take  mental, 
affective,  motor,  and  sexual  rest.  I  warned  his  friends 
against  the  common  delusion  that  a  man  in  that  state  needed 
to  be  "  cheered  up  "  specially.  My  experience  has  been  that 
such  cheering  up  is  a  natural  process  that  will  come  of  itself 
when  the  brain  attains  its  normal  trophic  and  energising 
power.  I  have  seen  many  patients  still  further  exhausted 
by  the  violent  and  continuous  efforts  made  to  cheer  them 
up. 

I  gave  my  opinion  as  to  the  prognosis  that  he  would 
probably  get  over  each  attack  as  they  came  on  him,  but  that 
he  should  be  extraordinarily  careful  when  he  came  towards 
old  age,  and  said  he  would  probably  be  an  old  man  before 
his  time. 

As  to  prophylaxis,  I  recommended  liim,  when  he  got 
better,  to  do  his  work  witb  great  system  and  order,  cutting 
up  his  day,  like  the  face  of  a  chess  board,  into  regular 
divisions,  and  filling  in  each  with  regular  work,  or  recreation, 
or  rest.  I  told  him  to  weigh  liimself  every  month,  and 
whenever  he  found  he  had  lost  3  lbs.  to  stop  work  and  take 
a  change  or  a  sea  voyage.  I  recommended  the  bromide  of 
potassium   for  sleeplessness,  in  25  grain  doses,  if   fresh  air 


STATES  OF   MENTAL  DEPEESSION.  37 

would  not  do,  but  I  should  now  say  paraldehyde  in  drachm 
doses. 

That  is  the  type  of  a  very  mild  cam  of  simple  melancJioUa, 
caused  by  over  brain- work  in  a  person  predisposed  to  it  by 
heredity.  In  such  a  case  it  seems  as  if  brain  anaemia  was 
present,  the  morning  exacerbation  after  the  physiological 
sleep  anaemia  pointing  to  this,  relief  being  obtained  by 
anything  that  determined  more  blood  to  the  organ. 

As  an  example  of  simple  melancholia  loith  partial  paralysis 
of  volition,  and  of  that  particular  kind  of  morbidness  which 
consists  in  never  "making  up  one's  mind,"  in  being  subject 
to  "fixed"  and  "imperative  ideas"  taking  unwilling  possession 
of  the  mind,  along  with  a  subtile  kind  of  morbid  introspection 
and  morbid  magniti cation  of  small  things,  the  following  graphic 
case  of  A.  C.  is  of  much  interest : — She  was  a  young  lady  who 
had  worked  far  too  hard  at  school,  and  so  had  probably  pro- 
duced impaired  nutrition  of  her  convolutions.  I  quote  from 
her  own  description  of  her  mental  state. 

"  I  watch  every  action,  word,  and  thought,  constantly 
questioning  them,  accounting  for  them,  excusing  them,  or 
deprecating  them.  Every  day  I  rise  I  wish  to  be  happy  like 
the  others.  I  will  not  torture  my  brain.  It  is  a  sin  to  steal 
my  own  happiness  and  that  of  others.  I  reason,  resolve,  and 
hope ;  but  the  greater  the  effort  to  be  free  the  greater  the 
struggle.  I  have  been  so  oppressed  with  this  unspeakable 
distress  that  I  feel  as  if  I  were  two  persons — the  one  tyranni- 
cally demanding  to  be  gratified,  the  other  protesting  and 
pleading.  I  am  often  in  despair,  and  feel  my  life  a  burden. 
At  night  I  am  glad  the  day  is  done ;  in  the  morning  I  am 
in  terror  the  day  will  be  a  repetition  of  the  former.  The  most 
trivial  incident  will  occupy  my  mind ;  I  discuss  it  in  all  its 
bearings,  telhng  myself  all  the  time  it  is  not  worthy  of  my 
consideration.  Some  one  speaks  to  me,  or  some  one  is 
talking.  If  the  former,  I  answer  (often  very  abstractedly) 
with  the  feeling  that  there  is  something  on  my  mind ;  then  I 
return   to   the   triviality.     If   I   have   forgotten   it    I   must 


38  STATES   OF   MENTAL  DEPRESSION. 

remember  it,  and  then  with  a  distinct  eftbrt  put  it  away  from 
my  mind.  It  steals  back.  I  tell  myself  that  I  have  already 
discussed  it,  but  I  must  repeat  the  whole  matter  to  myself, 
and  that  with  no  ordinary  process  of  thought.  I  seem  to 
feel  a  strange  strain  on  my  memory,  and  again  I  have  to 
use  an  effort  to  banish  this  notliing.  Again  it  will  arise  and 
be  dismissed ;  and  I  number  the  times  as  carefully  as  if  much 
depended  on  it.  The  efforts  to  dismiss  the  subject  cause  the 
blood  to  rush  to  my  head,  the  perspiration  to  break,  and  I 
often  find  my  hands  clenched  in  the  struggle.  All  through 
this  I  can  bear  a  calm  exterior,  no  one  knowing  how  I  am 
tortured.  This  fret  goes  on  in  every  circumstance.  I  try  to 
divert  myself,  and  go  here  and  there,  seek  the  conversation 
of  some  one,  seek  sohtude,  try  the  piano,  then  a  book,  until 
I  feel  Hke  a  hunted  creature.  This  strain  upon  my  mind 
I  cannot  endure.  I  seem  paralysed.  I  cannot  perform 
anything  I  wish  to  do,  though  I  spend  any  amount  of  energy 
in  fretting. 

"  In  the  most  critical  moments  of  my  life,  when  I  ought  to 
have  been  so  engrossed  as  to  leave  no  room  for  any  secondary 
thoughts,  I  have  been  oppressed  by  the  inability  to  be  at 
peace.  And  in  the  most  ordinary  circumstances  it  is  all  the 
same.  Let  me  instance  the  other  morning  I  went  to  walk. 
The  day  was  biting  cold,  but  I  was  unable  to  proceed  except 
by  jerks.  Once  I  got  arrested — my  feet  in  a  muddy  pool. 
One  foot  was  hfted  to  go,  knowing  that  it  was  not  good  to  be 
standing  in  water,  but  there  I  was  fast,  the  cause  of  detention 
being  the  discussing  with  myself  the  reasons  why  I  should 
not  stand  in  that  pool." 

The  morbid  "  watching  of  herself,"  as  she  caUs  it,  is  a  very 
common  psychological  phenomenon.  The  morbid  doubting, 
too,  and  inability  to  make  up  her  mind  to  action,  is  also 
common.  I  know  a  young  man  of  a  very  neurotic  family, 
A.  D.,  whose  sister,  C.  E.,  was  insane  and  laboured  under  the 
variety  of  mania  that  I  shall  describe,  who  suffered  from 
simple   melanchoHa,  but   still  more   from   tliis  "insanity   of 


STATES   OF   MENTAL  DEPRESSION.  39 

doubt,"  for  he  would  stop  half  an  hour  in  dressing  to  decide 
which  stocking  to  put  on  first,  and  has  been  known  to  stand 
for  two  hours  where  three  roads  met,  trying  to  decide  which 
to  take.  If  hurried  or  forced  during  those  morbid  periods  of 
doubt,  he  suffers  intense  mental  pain,  and  is  inclined  to 
resist  dictation.  Such  cases  throw  much  Hght  on  many  of 
the  resistive  and  apparently  "  obstinate  "  moods  of  the  insane, 
who  are  often  too  much  affected  intellectually  to  describe 
their  feelings,  or  to  give  their  reasons  for  their  conduct. 

To  return  to  A.  C,  whose  letter  I  have  quoted.  She 
could  not  walk  far,  had  palpitation  when  she  ran,  had  no 
courage  to  ride,  had  much  confusion  and  pain  at  vertex  of 
head  after  reading  or  thinking  hard.  She  was  fairly 
nourished,  slept  well,  menstruation  was  regular,  and  she 
looked  a  sweet,  bright,  intelligent  girl. 

During  adolescence  she  had  suffered  much  from  neuralgia, 
severe  headaches,  depression  of  spirits,  and  a  few  attacks  of 
hysteria,  and  had  no  surplus  stock  of  nerve  energy  or  trophic 
power.  She  had  used  up  in  school-work  the  energy  that 
ought  to  have  gone  to  build  up  her  brain  and  body.  I 
prescribed  life  in  the  open  air,  no  reading,  no  work  amongst 
the  poor  (that  had  strained  her  by  over-sympathy  with  them), 
to  hve  largely  on  non-stimulating  fattening  food,  to  take 
bromide  and  iodide  of  potassium  in  small  doses,  and 
strychnine  meantime  till  she  could  get  to  Schwalbach  and 
take  the  baths  and  chalybeate  waters  there.  This  she  did, 
and  improved  greatly. 

I  have  on  several  occasions  met  with  cases  of  this  type  in 
women  of  a  nervous  diathesis  or  heredity,  both  before  and 
after  marriage,  in  which  the  morbid  doubting  and  introspec- 
tion were  very  prominent  features. 

I  have  met  with  many  other  cases  very  similar  to  this,  but 
each  one  with  its  own  individual  features.  It  appears  to  me 
no  diseases  are  so  individuaHsed  as  mental  diseases.  It  seems 
as  if  the  brain  showed  its  infinite  complexity  over  every  other 
organ  by  this  extraordinary  variety  in  its  derangements. 


40  STATES   OF   MENTAL  DEPEESSION. 

Such  attacks  of  simple  melancholia  sometimes  occur  in 
young  persons  at  puberty  or  adolescence.  In  such  cases  there 
is  always  a  strong  hereditary  tendency  towards  the  neuroses, 
if  not  to  mental  disease.  I  was  asked  to  see  A.  E.,  a  girl  of 
15,  some  of  whose  mother's  family  had  heen  insane,  who  was 
clever  and  studious,  though  at  one  time  wild  and  mismanaged, 
who,  after  hearing  a  sermon  one  Sunday,  hecame  very  de- 
pressed, insisted  on  praying  with  the  other  girls  in  the  school, 
and  was  a  httle  excited  and  demonstrative.  The  great 
feature  of  her  case  was  one  which,  in  different  forms,  is  very 
common  in  young  brains  that  are  subject  to  the  psychoses, 
viz.,  a  sort  of  automatic,  rhythmical,  emotional  movement. 
She  became  what  she  and  those  about  her  called  "agonised" 
when  left  alone,  that  is,  she  would  get  into  a  state  of  in- 
tensely depressed  brain  action, — kneehng,  uttering  over  and 
over  again  rhythmical  expressions  of  prayer,  swaying  her 
body  backwards  and  forwards,  and  wringing  her  hands  at 
intervals.  When  with  others,  or  at  her  lessons,  she  would 
appear  to  be  quite  well,  but  reserved  and  shy,  and  could  not 
learn  her  lessons  so  well  as  before,  and  had  no  tendency  to 
romp.  She  was  becoming  paler  and  thinner,  though  she  ate 
well.  She  had  never  menstruated.  Her  intelhgence,  when 
I  saw  her,  was  normal ;  and  she  said  she  was  quite  well,  and 
would  admit  no  depression.  She  said  she  had  headache  in 
one  temple,  and  felt  her  back  weak.  I  sent  her  at  once  to 
the  country,  to  ride,  walk,  hve  in  the  open  air,  to  take  aloes, 
iron,  and  quinine,  to  read  Httle,  not  to  go  to  church  for  a 
short  time,  to  give  up  coffee  and  tea,  and  animal  food,  but 
take  milk  and  eggs  ad  libitum.  At  first,  for  a  month  or  two, 
she  used  to  feel  depressed,  and  shghtly  agitated  before  people, 
but  soon  got  girhsh,  romping,  and  quite  well.  After  a  tour 
in  Switzerland  she  returned  fat,  cheerful,  and  vigorous,  with 
no  undue  rehgious  emotionahsm.  She  menstruated  soon.  If 
one  had  the  guidance  of  such  a  hfe,  much,  I  think,  might  be 
done  by  prophylaxis  to  ward  off  attacks  of  the  neuroses. 
But  one  great  contingency  it  is  most  difficult  to  know  how  to 


STATES   OF   MENTAL   DEPKESSION,  41 

meet,  viz.,  marriage.  If  such  a  woman  marries,  she  runs 
many  risks  in  pregnancy,  childbirth,  and  lactation,  and 
she  is  likely  to  have  weakly  cliildren ;  if  she  remains  single, 
she  has  nearly  as  many  hazards  in  unused  functions,  hysteria, 
unsatisfied  cravings,  objectless  emotion,  and  want  of  natural 
interests  in  life.  For  herself  she  would  get  more  happiness 
in  life  by  marrying ;  for  the  world  it  is  better  that  she  should 
not.  But  prophylaxis  in  mode  of  living,  attention  to  keep 
the  body  nutrition  at  all  times  up  to  the  highest  mark,  and 
early  treatment  of  the  beginnings  of  the  evil  would,  I  am 
sure,  greatly  ward  off  the  risks  of  an  attack.  I  need 
hardly  say  that  the  "  cause  "  assigned — viz.,  the  sermon  she 
heard — had  in  reahty  less  to  do  with  the  disease  than  the 
brain  she  took  to  church,  predisposed  by  heredity,  exhausted 
by  study  and  the  unnatural  hfe  at  a  boarding-school,  starved 
of  fresh  air,  and  rendered  unstable  by  the  physiological  crisis 
of  commencing  menstruation.  And  here  I  would  say,  once 
for  all,  about  unusual  religious  services,  exciting  preaching, 
and  "revival  meetings,"  that,  as  a  physician,  I  have  no 
objection  to  them  at  all,  rather  the  contrary,  but  I  think  they 
are  only  suited  to  stolid  healthy  brains,  and  should  on  no 
account  be  attended  by  persons  with  weak  heads,  excitable 
dispositions,  and  neurotic  constitutions. 

The  immense  variety  that  the  combination  of  different 
mental  or  nervous  symptoms  is  capable  of  producing  comes 
out  in  this,  the  simplest  of  all  mental  ailments.  In  some 
cases  the  mental  pain  is,  as  it  were,  negative  rather  than 
positive,  there  being  simply  absence  of  pleasure;  in  others 
there  is  a  simple  blunting  of  the  emotions,  with  a  tinge  of 
depression;  in  others,  again,  the  normal  gaiety  disappears; 
in  others  there  is  a  paralysis  of  energy ;  in  others  a  sudden 
ceasing  to  care  anything  about  the  usual  interests  of  hfe;  in 
others  a  natural  suspiciousness  of  temperament  becomes 
morbid  and  causes  mental  pain ;  in  others  a  natural  diffidence 
of  disposition  increases  so  as  to  become  a  disease  and  to  cause 
intense  unhappiness ;  and  in  others  it  is  a  morbid  f earf ulness. 


42  STATES   OF   MENTAL   DEPRESSION. 

It  would  swell  the  bulk  of  this  lecture  to  utterly  impossible 
proportions  were  I  to  give  cases  illustrative  of  all  these  con- 
ditions, but,  to  show  the  ordinary  types,  I  give  one  or  two. 
I  was  once  consulted  about  a  lady,  A.  F.,  about  40  years  of 
age,  who  was  said  to  have  had  a  similar  attack  some  years 
before,  and  to  have  recovered.  She  had  given  up  her 
business,  and  had,  therefore,  no  serious  interests  in  Hfe.  She 
had  been  for  some  months  ill.  When  well,  she  had  been 
a  clever  active  woman  in  body  and  mind,  had  conducted  a 
business  enthusiastically  and  profitably,  was  sociable  and  a 
favourite  with  her  friends.  When  I  saw  her  she  had  Httle 
conscious  mental  pain,  but  she  had  no  mental  or  bodily 
pleasure.  She  had  no  energy — no  interest  in  anytlaing.  She 
had  no  delusion,  except  an  unreasoning  belief  that  she  could 
not  get  better.  She  was  utterly  careless  about  her  dress,  or 
appearance,  or  cleanliness.  She  was  obstinate  about  some 
things ;  she  cared  for  nothing  or  nobody,  not  even  her  life, 
and  was  perfectly  conscious  of  her  condition.  The  only 
thing  in  which  she  took  any  interest  was  talking  about  her 
symptoms.  Her  memory  was  good,  her  reasoning  power  was, 
in  the  main,  good.  She  was  thin  and  flabby.  She  would  do 
nothing  she  was  told,  and  needed  the  guidance  of  others  for 
her  recovery.  She  recovered  after  about  tliree  years,  having 
then  passed  the  cHmacteric. 

I  have  seen  many  cases  where  the  mental  symptom  of 
depression  was  so  subsidiary  to  general  nervous  prostration, 
incapacity  to  walk,  work,  to  digest  food,  or  to  fatten,  that  it 
was  overlooked.  I  knew  one  case,  A.  G.,  where,  as  the 
result  of  many  causes  of  nervous  exhaustion,  along  with  mild 
mental  depression,  indigestion,  and  the  most  distressing 
weakness,  the  cardiac  innervation  became  so  weak  that  the 
recumbent  position  had  to  be  kept  almost  constantly  for  a 
time  in  case  of  syncope.  She  recovered  in  two  years  under 
tonics,  changes  of  scene,  and  a  warm  climate.  Many  of  these 
cases  are  of  the  same  essential  nature  as  typical  mild  melan- 
choha.     American  medical  authors  have  much  to  say  about 


STATES   OF  MENTAL  DEPRESSION.  43 

such  nervous  exhaustion  and  prostration — the  Neurasthenia 
of  Beard.  For  the  cure  of  some  of  these  cases  a  plan  of 
treatment  has  been  revived,  which  is  certainly  not  apphcable 
to  many  cases  of  melancholia  in  my  experience.  It  is  that 
of  massage,  or  making  the  muscles  contract  and  the  blood 
circulate  faster  by  rapid  percussion,  squeezing  and  rubbing 
the  body  all  over  every  day,  and  over-feeding  the  patient 
while  she  is  confined  to  bed,  instead  of  walking  in  the  fresh 
air.  Astonishing  temporary  results  are  got  in  some  cases  in 
the  way  of  fattening,  but  I  have  seen  along  with  those  an 
aggravation  of  the  mental  symptoms  in  melancholies.  It 
seems  as  if  the  air  and  climate,  and  the  mode  of  life  and 
education  in  some  parts  of  America  were  so  stimulating,  that 
the  brain  there  sometimes  exhausted  both  its  trophic  and 
energising  power,  and  paid  the  penalty  by  prolonged  periods 
of  "  Neurasthenia."  The  natural  cure  would  seem  change  to 
a  more  sleepy  chmate.  I  think  that  a  modified  system  of 
massage  is  most  suitable  for  some  early  melancholies,  where 
innutrition  is  a  very  marked  symptom,  and  where  other 
measures  are  not  succeeding  massage  with  the  patient  con- 
fined to  bed  may  be  tried.  Use  it,  in  fact,  as  a  supplementary 
kind  of  exercise. 

There  are  some  instances  where  the  higher  affective  Ufe  is 
paralysed,  while  the  lower  appetites  and  propensities  are  left 
intact,  if  not  actually  increased.  A  mildly  melancholic 
patient  once  said  to  me,  "I  canna  think,  canna  do  anything, 
canna  care  for  anything — wife  or  children,  or  anything  at  all, 
but  meat,  meat !  If  they  were  all  lying  dead  I  would  not 
care  a  curse  if  I  get  meat." 

In  certain  other  cases  there  are  extraordinary  combinations 
of  mental  symptoms  along  with  the  mental  depression,  of 
which  this  is  an  example  with  a  morbid  fear  of  forgetting 
names  and  words: — 

A.  H.,  set,  64.  Disposition  cheerful.  Temperament  san- 
guine, but  not  a  "  nervous  "  man  at  all.  Habits  industrious, 
steady,  and  accurate,  but  somewhat  sedentary.     A  clever  and 


44  STATES   OF   MENTAL  DEPEESSION. 

intelligent  "business  man.  Mother  died  of  some  brain  affection, 
without  distinct  mental  disease.  The  only  other  predisposing 
cause  was  his  time  of  hfe — the  cHmacteric,  The  exciting 
cause  of  the  aggravation  of  the  mental  state  which  necessi- 
tated his  coming  to  this  Asylum  was  the  death  of  a  sister, 
His  present  attack  has  been  of  gradual  onset,  beginning  in  a 
very  mild  way  some  years  back,  getting  worse,  and  only 
assuming  a  form  that  could  be  reckoned  technical  insanity 
four  months  ago.  He  began  by  being  fanciful  and  disiacHned 
for  bodily  or  mental  exertion ;  in  fact,  a  kind  of  morbid 
laziness  came  over  him.  Laziness  is  more  often  a  real  disease 
than  is  commonly  imagined  ;  it  simply  means,  in  those  cases, 
diminished  evolution  of  the  higher  nerve  energy.  He  gradu- 
ally and  steadily  got  worse,  falling  more  under  the  influence 
of  his  morbid  fancies.  They  produced  insane  conduct  five 
months  ago  which  showed  itself  as  morbid  restlessness,  shout- 
ing, and  acting  on  his  unfounded  suspicions.  He  suspected 
that  people  were  plotting  against  him,  that  there  was  a 
society  in  the  next  street,  the  members  of  which  got  into  his 
room  at  night  and  stole  Ms  clothes  and  watch.  He  got  into 
silly  conservative  habits,  so  that  the  sKghtest  new  way  of  the 
house  was  most  disagreeable  to  liim.  He  could  not  be  got  to 
go  out  and  walk,  or  to  attempt  business.  Once  he  threatened 
to  commit  suicide  with  a  razor,  but  seemed  to  have  no  serious 
intention  to  hurt  himself.  His  memory  became  impaired  in 
regard  to  some  things,  and  he  thought  it  worse  than  it  really 
was.  His  affection  for  his  relations  diminished,  and  he  lost 
his  social  instincts. 

On  his  admission  into  the  Asylum  he  was  mildly  depressed. 
His  morbid  suspicions  seemed  not  only  to  be  a  symptom  of 
the  disease,  but  also  a  cause  of  depression.  He  was  restless, 
fidgety,  easily  startled,  and  perversely  irritable.  There  was 
some  limited  enfeeblement  of  mind  in  regard  to  certain  things, 
e.g.,  inabihty  to  identify  famihar  persons  and  places,  or  to 
recall  events  at  will ;  he  had  groundless  fears,  and  liis  manner 
was  hesitating.     His  memory,  in  regard  to  most  matters,  was 


STATES   OF   MENTAL   DEPKESSION.  45 

unimpaired,  but  in  regard  to  names  it  was  most  peculiar,  for 
he  had  a  feeling,  almost  amounting  to  terror,  that  he  would 
forget  some  familiar  name.  His  volition  was  weak  as  regards 
its  positive  action,  but  there  was  a  good  deal  of  obstinacy. 
In  appearance  he  was  fairly  nourished,  but  flabby  and  sHghtly 
paretic  looking.  After  a  time  his  mental  depression  centred 
round  his  fear  of  not  "  remembering  names,"  In  reahty,  he 
would  remember  them  pretty  well,  but  he  would  get  very 
unhappy,  sometimes  excited,  and  most  irritable  through  the 
morbid  fear  that  he  would  forget  them.  In  reading  the 
newspaper  he  would  mark  certain  names  down  on  paper  lest 
he  should  forget  them.  He  would  come  up  to  me  and  ask  in 
the  most  earnest  tone,  as  if  his  life  depended  on  the  answer 
— "Doctor,  can  you  tell  me  the  name  of  that  burn  in  Fife  I 
fished  in  in  1850  ?  I  can't  get  it,  and  it  makes  me  miserable," 
At  times  it  seemed  as  if  he  had  a  dreamy  mental  vision  of 
great  rows  of  long  botanical  and  topographical  names,  whose 
exact  spelhng  and  pronunciation  he  could  not  make  out,  and 
that  this  made  him  utterly  miserable.  He  got  very  stout 
after  about  six  months,  and  went— much  against  his  will — to 
the  Asylum  seaside  house,  where  he  still  further  improved, 
and  then  unwilhngly  went  home,  where  he  lived  for  ten  years 
a  mentally  depressed,  pecuhar  life,  fearing  the  loss  of  words 
and  names  still.  He  then  got  so  troublesome  that  he  had  to 
be  sent  back  to  the  Asylum,  Many  of  liis  peculiarities  result 
from  his  old  methodical  habits  remaining  in  an  insane  and 
grotesque  form.  He  has  been  16  years  ill,  and  the  slightly 
paralytic  symptoms,  which  have  now  increased,  are  proof  to 
me  that  he  has  some  brain  degeneration,  probably  combined 
with  a  good  deal  of  convolutional  atrophy  (Plate  II.,  fig.  5). 

In  the  cases  I  have  referred  to  the  condition  of  simple 
melancholia  has  been  the  mental  disease  from  beginning  to 
end,  but  very  often  it  is  merely  a  stage  in  the  clinical  history, 
and  the  case  soon  assumes  a  deeper  and  diff'erent  form  of 
depression,  or  in  some  cases  it  passes  into  mania. 

Simple  melanchoHa  sometimes  becomes  chronic,  of  which 


46  STATES   OF   MENTAL  DEPRESSION. 

the  following  case  was  an  example,  having  depression,  but 
great  self-control  hefore  strangers,  infelleetual  vigour,  morbid 
sensitiveness  as  to  people  knowing  about  her  illness,  tvant  of  real 
enjoyment  of  food,  but  eating  plenty,  grimacing  and  swearing 
in  secret,  almost  tearless  weeping,  wringing  her  hands,  and 
nervous  jerkings : — 

A.  J.,  set.  63.  Widow.  ISTo  children.  Temperament 
melancholic,  and  diathesis  nervous,  but  disposition  lively,  and 
very  energetic.  Very  intelligent ;  habits  active ;  well  edu- 
cated and  well  bred.  For  four  years  she  had  been  depressed, 
unsocial,  morbidly  shy,  and  in  great  dread  lest  her  friends 
should  know  there  was  anything  wrong.  Cannot  make  up 
her  mind  about  anything,  and  to  any  new  proposal  whatever 
is  always  averse ;  changed  in  ways ;  not  so  particular  as  to 
dress  and  cleanliness  as  in  health  (this  is  very  common  in 
similar  cases),  and  more  penurious  (also  common).  When 
she  sees  strangers  or  friends  she  can  talk  and  behave  very 
well,  and  seems  almost  to  enjoy  their  company.  Always 
objects  to  going  anywhere,  but  does  not  Hke  to  be  left  at 
home.  Has  no  power  of  coming  to  any  resolution,  but  much 
of  passive  resistance  and  objection.  Conceives  very  strong 
dishkes  and  suspicions,  reads  all  day  and  very  quickly,  but 
will  not  sew,  or  knit,  or  play ;  very  acute  and  observant ; 
very  sure  she  will  never  get  well.  As  she  sits  and  talks  to 
one,  she  never  looks  one  in  the  face,  and  fidgets  and  jerks, 
and  sometimes  makes  faces.  When  alone  she  swears  and 
uses  abominable  language,  tliis  being  of  course  utterly  foreign 
to  her  real  nature  and  former  habits.  She  says  she  cannot 
help  it,  and  deplores  it, — a  common  symptom  in  such  cases. 
She  says  she  never  sleeps,  but  this  is  not  true,  though  she 
sleeps  badly  at  times  and  walks  about  the  room. 

For  treatment,  I  put  this  lady  on  very  many  things. 
Opium  did  harm,  and  so  did  the  vegetable  narcotics,  all  but 
cannabis  indica  in  15-drop  doses,  which  I  gave  temporarily 
with  good  result  when  she  was  unusually  restless  and  sleep- 
less, combined  with  30  grains  of  the  bromide  of  potassium.     I 


STATES   OF   MENTAL   DEPRESSION.  47 

gave  her  in  succession  arsenic,  strychnine,  iron,  quinine,  the 
mineral  acids,  the  hypophosphites,  salt  baths,  fresh  air,  and 
walking  ad  libitum,  cod-liver  oil,  maltine,  employment,  milk, 
fruit,  fresh  vegetables,  and  farinaceous .  and  fish  diet,  largely 
ringing  the  changes  on  the  tonic  medicines,  with  Friedrichs- 
hall  water  every  other  morning  for  the  bowels.  The  course 
of  arsenic  did  much  good,  being  followed  by  an  increase  of 
body  weight.  Though  she  did  not  get  well,  yet  undoubtedly 
she  got  fatter  and  happier  and  more  comfortable  to  do  with, 
and  remains  so  now  at  the  end  of  ten  years. 

Simple  melancholia  is  in  most  cases  curable;  it  does  not 
commonly  require  treatment  in  an  asylum,  when  the  means 
of  the  patient  admit  of  suitable  attendance,  change,  and  treat- 
ment elsewhere ;  it  never  kills  directly  by  exhaustion,  and 
seldom  ends  in  dementia.  The  exceptions  to  its  curability 
occur  in  the  very  advanced  periods  of  hfe,  when  the  brain  is 
retrogressing  or  degenerating,  where  the  heredity  is  very 
strong,  or  where  it  occurs  as  an  accompaniment  of  organic 
brain  disease,  and  this  is  not  uncommon  when  there  is  a  strong 
neurotic  heredity  as  well  as  such  organic  disease. 

Simple  depression  frequently  precedes  other  forms  of  mental 
disease  than  melancholia,  some  authorities  going  the  length  of 
saying  that  it  is  the  first  symptom  of  all  kinds  of  insanity. 
My  experience  is  that  it  is  not  a  necessary  prelude  to  mania 
or  to  general  paralysis,  but  that  in  a  slight  degree  it  is  a  very 
frequent  one  indeed. 

Hypochondriacal  Melancholia. — The  next  variety  of  melan- 
cholia is  a  rather  well-marked  one.  In  seriousness  it  exceeds 
the  simple  form.  It  is  further  away  from  mental  health, 
psychologically  and  bodily.  The  symptoms  are  more  decided 
and  positive.  Along  with  the  affective  derangement  there 
is  more  judging  aberration,  and  less  inhibition  over  morbid 
speech  and  conduct ;  yet  the  radical  instincts  and  habits  of 
hfe  are  not  entirely  perverted,  nor  is  the  self-control  so  lost  as 
in  the  severer  varieties  of  the  disease.  The  mental  pain  has 
a  certain  superficialness  and  want  of  intensity,  and  the  cause 


48  STATES   OF   MENTAL   DEPRESSION. 

of  it  is  always  stated  by  the  patient  to  be  diseases  or  disorder 
of  tbe  bodily  organs  or  functions  that  are  not  real,  or,  if  real, 
are  exaggerated  in  the  patient's  mind  out  of  all  proportion  to 
their  actual  severity.  As  simple  melanchoha  has  a  sane 
initial  period,  and  many  cases  are  never  legally  or  technically 
insane  at  all,  so  hypochondriacal  melancholia  has  generally  a 
sane  stage  and  a  sane  twin  brother  called  hypochondriasis, 
which  is  usually  so  hghtly  thought  of,  and  so  misunderstood, 
as  to  be  for  the  most  part  thought  a  subject  of  laughter  to 
the  patient's  friends,  and  is  always  popularly  talked  of  as 
being  a  state  that  the  patient  has  got  into  through  his  own 
fault,  and  could  get  out  of  by  the  exercise  of  his  own  vohtion. 
In  hypochondriacal  melancholia  a  sense  of  ill-being  is  sub- 
stituted for  the  healthy  pleasure  of  living,  but  the  ill-being  is 
locaHsed  in  some  organ  or  function  of  the  body.  The  patient's 
depressed  feehngs  all  centre  round  himself,  his  health,  or  the 
performance  of  his  bodily  or  mental  functions.  He  is  all  out 
of  sorts,  he  cannot  digest  his  food,  his  bowels  will  never  act, 
his  kidneys  or  Hver  are  wrong,  he  has  no  stomach,  his  heart 
is  weak,  and  he  asks  you  to  feel  his  pulse,  which  is  just  going 
to  stop  beating.  He  is  paralysed,  and  will  not  move  a  hmb 
till  he  forgets  his  fancy  for  a  moment;  he  cannot  think, 
because  his  brain  is  made  of  lead ;  he  is  made  of  glass  and 
will  break  if  roughly  handled.  There  are  no  Hmits  to  the 
fancies  of  the  hypochondriac  or  the  hypochondriacal  melan- 
cholic. The  way  we  distinguish  them — the  sane  from  the 
insane  hypochondriac — is  this  :  a  man  may  have  any  con- 
ceivably absurd  fancy  about  himself,  but  if  he  can  do  his 
work  in  the  world,  and  does  no  harm  to  himself,  and  has  a 
fair  amount  of  self-control ;  if  he  can  pick  himself  up  mentally 
and  in  conduct  at  will,  and  has  the  power  to  stop  talking  of 
his  fancies  when  he  wishes,  even  though  he  revels  in  the 
descriptions  of  his  own  evacuations,  consults  all  the  doctors 
he  can  afford  to  pay  or  who  will  give  him  advice  without  pay, 
and  swallows  all  the  physic  he  can  afford  to  buy,  we  call  him 
merely   a  hypochondriac ;    but   if  he   has   real  and  intense 


STATES   OF   MENTAL   DEPEESSION.  49 

mental  depression  that  lie  cannot  throw  off,  if  he  loses  his  self- 
control,  cannot  do  his  work,  outrages  decency  openly,  practises 
things  that  will  soon  end  his  days,  or  threatens  to  take  away 
his  own  life,  and  cannot  at  will  withdraw  his  mind  and  speech 
from  his  delusions,  then  we  call  him  a  melancholic  of  the 
hypochondriacal  type,  and,  if  necessary,  put  him  under 
restraint.  But,  as  you  see,  there  is  no  line  of  demarcation. 
The  one  condition  is  often  the  first  stage  of  the  other.  From 
a  physiological  point  of  view  the  afferent  impressions  sent  up 
to  the  brain  from  the  organ  impHcated  in  the  delusion  are 
unpleasant,  instead  of,  as  they  should  be,  pleasant.  The 
secondary  cause  may  be  real  peripheral  disorder.  A  man's 
liver  may  not  be  working  well,  and  causing  him  uneasiness, 
or  his  stomach  may  not  be  doing  its  work  well,  or  his  bowels 
may  be  costive — they  usually  are — or  he  may  have  actual 
disease  in  the  part  that  he  says  is  wrong,  but  none  of  these 
things  would  cause  the  mental  phenomena  of  hypochondria 
if  the  man's  brain  convolutions  were  working  healthily ; 
therefore  the  real  cause  must  be  referred  to  the  brain. 

The  following  was  a  case  of  hypochondriacal  melancholia  of 
short  duration  : — 

A.  K.,  set.  67,  unmarried.  Disposition  eccentric,  suspicious, 
obstinate,  and  unsocial.  Habits  sober,  but  not  continuously 
industrious.  Has  had  three  previous  attacks,  all  of  melancholia 
of  a  hypochondriacal  character,  treated  in  an  asylum.  No 
ascertained  heredity  towards  the  neuroses.  It  was  said  that 
he  had  a  fall  on  his  head  when  he  was  ten  years  old,  and  had 
never  been  "right"  since,  but  I  attached  no  importance  to 
this  story.  The  exciting  cause  of  his  attack  was  said  to  be 
masturbation,  but  whether  this  was  a  cause  or  a  symptom,  I 
could  not  clearly  make  out.  He  was  said  to  have  become 
depressed  three  months  ago,  to  have  had  suicidal  feelings  to 
which  he  gave  loud  expression,  to  have  lost  his  self-confidence  ; 
and  he  became  perfectly  helpless  and  sleepless,  according  to 
his  own  account.  He  has  eaten  voraciously  all  the  time,  and 
has  not  fallen  off  in  looks  or  weight.     He  came  to  the  Asylum 

D 


50  STATES   OF  MENTAL  DEPRESSION. 

voluntarily,  and  considered  his  case  was  so  urgent  tliat  lie 
sent  for  me  out  of  church.  He  said  he  felt  nervous  and 
depressed,  and  was  afraid  every  minute  that  he  would  lose 
his  self-control.  He  was  full  of  fancies  as  to  the  bad  state  of 
Ms  own  bodily  health,  that  his  bowels  were  very  costive,  and 
that  he  had  no  appetite  whatever.  He  wanted  to  be  most 
carefully  examined  as  to  the  state  of  his  lungs  and  heart,  and 
more  especially  as  to  his  sexual  organs.  He  had  a  real 
chronic  enlargement  of  one  of  liis  testicles,  and  insisted  that 
he  had  a  sore  on  his  penis,  the  existence  of  which  required  a 
magnifying  glass  to  determine.  His  temperature,  pulse,  and 
all  liis  organs  were  normal ;  he  was  well  nourished.  He 
insisted  he  had  a  serious  skin  eruption,  which  was  really  a 
httle  acne  on  his  back.  He  was  obtrusively  suicidal  in  his 
expressions,  though  it  ought  to  have  been  clear  to  him  that  if 
he  was  prevented  from  putting  an  end  to  his  hfe  he  would 
soon  die  of  some  one  of  the  numerous  diseases  he  had.  He 
remained  in  this  state  for  about  two  months  and  a  half,  and 
was  subjected  to  rather  a  calm  but  strict  discipline  at  first. 
He  was  acute  about  money  matters,  most  fault-finding  as  to 
his  food,  and  said  he  did  not  sleep,  when  in  reahty  he  snored 
all  night.  He  was  incHned  to  be  discontented  because  he  did 
not  receive  that  amount  of  attention  which  his  case  deserved. 
I  never  laughed  at  him,  or  pooh-poohed  him,  nor  courted  his 
conversation,  but  put  him  on  tonics,  and  made  him  live  in  the 
fresh  air,  and  occupy  himself  as  much  as  possible.  He 
improved,  and  was  nearly  recovered  in  three  months  from  his 
admission,  in  other  six  months  being  quite  lively,  and  he  then 
got  married.  After  three  years  he  had  another  such  attack, 
from  wliich  he  also  recovered. 

Here  is  another  case  of  hypocliondriacal  melancliolia  of  a 
deeper  and  viore  serious  nature,  and  of  a  longer  dui'ation,  of 
the  same  type,  the  cause  being  disappomtment ;  the  sensations, 
appetites,  and  propensities  being  changed  ;  travel  aggravating 
the  symptoms,  wliich  were  very  demonstrative,  with  suicidal 
talk  and  ludicrous  attempts  ;  strychnine,  discipline,  and  fresh 


STATES   OF   MENTAL   DEPRESSION.  51 

air  having  a  very  good  effect,  with  a  great  gain  in  weight  in 
six  months  : — 

A.  L.,  set.  38.  Temperament  melanchoHc.  Disposition  quiet, 
thoughtful,  gloomy,  energetic,  enthusiastic.  Habits  temperate, 
and  very  hard  working.  Fond  of  active  work  rather  than 
study.  Had  had  a  previous  attack,  lasting  three  months,  of 
the  same  character  as  this  about  to  be  described,  but  not  so 
severe,  and  treated  at  home.  Maternal  uncle  and  aunt 
eccentric,  if  not  insane.  The  existing  cause  of  the  present 
attack  was  a  disappointment.  It  began  by  simple  depression 
and  incapacity  for  professional  work.  The  bodily  symptoms 
were  at  first  sleeplessness,  and  then  a  curious  feeling  in  his 
head  as  if  it  were  made  of  lead.  His  thoughts  became  more 
and  more  concentrated  on  his  health  and  the  state  of  his 
organs.  His  appetites  and  propensities  changed.  Instead 
of  being  very  fond  of  animal  food,  he  could  not  eat  it  at  all. 
Instead  of  having  the  nisus  generativus  keenly,  and  indulging 
it  freely,  his  sexual  appetite  was  gone.  He  had  had  non- 
specific psoriasis  when  well,  and  it  had  disappeared — this  I 
have  noticed  in  insane  patients  very  often.  He  had  tried  the 
usual  plan  of  travel  and  change  of  scene,  but  he  had  been  the 
worse  for  it,  as  often  occurs  in  melancholia.  There  is  scarcely 
a  point  on  which  I  have  so  much  difficulty  in  the  early  treat- 
ment of  melancholia  as  whether  to  send  away  patients  to 
travel  or  not,  and,  if  they  are  to  go  from  home,  where  to  send 
them  to.  Quick  travelling,  and  going  to  many  places  in  a 
short  time,  is  nearly  always  bad  for  a  nervous  or  insane 
patient.  Big  noisy  hotels  and  an  exciting  life  are  also  nearly 
always  bad ;  but  then  one  must  have  change  of  some  sort, 
breaking  off  old  associations,  and  difi'erent  air,  and  scenery, 
and  employment.  The  fact  is,  that  no  definite  rules  can  be 
laid  down  on  this  subject ;  but  there  are  a  few  considerations 
that  help  to  guide  us.  In  the  very  early  stages  of  the  disea,se, 
when  the  mental  pain  is  merely  incipient,  travel  abroad  often 
does  good,  if  it  is  done  in  a  systematic,  methodical,  leisurely 
way.     If  the  disease  has  advanced  so  far  that  the  power  of 


52  STATES   OF   MENTAL  DEPRESSION. 

attention  is  nauch  impaired,  then  a  quiet  country  place,  where 
there  are  few  Adsitors,  is  best.  If  the  bodily  condition  is  very 
weak  and  exhausted,  travelling  often  does  more  harm  than 
good.  If  there  are  delusions  of  suspicion  very  strong,  so  that 
the  patient  is  always  imagining  that  people  are  looking  at 
him,  speaking  about  him,  following  him,  then  the  quieter  he 
is  kept  the  better.  In  many  cases  we  must  try  experimentally 
to  see  whether  travel  is  to  do  good  or  harm. 

On  admission  A.  L.  was  much  depressed,  and  very  demon- 
strative in  his  account  of  his  feelings  and  ailments.  He  could 
not  read,  he  said,  or  understand  what  he  read.  He  was  very 
suspicious,  tliinking  that  people  were  watching  him ;  imagining 
he  was  paralysed  in  sensation  and  partly  in  motion  ;  that  he 
had  no  appetite,  though  he  ate  voraciously,  and,  when  caught 
in  the  act,  saying  that  his  appetite  was  an  unreal,  unnatural 
one.  He  said  his  face  and  features  were  quite  changed,  and 
he  wailfuUy  contrasted  his  present  looks  with  his  former 
appearance.  He  went  and  made  faces  at  the  looking-glass, 
and  said  he  could  not  help  this.  Said  his  natural  affection 
for  his  wife  and  children  was  gone,  and  Ms  senses  of  taste 
and  smell  were  dulled,  but  there  was  no  evidence  of  it.  He 
says  liis  brain  felt  as  if  "made  of  lead,"  and  had  a  "con- 
tracted "  feehng.  He  was  well  nourished  and  muscular,  and 
all  his  organs  were  sound  but  his  digestive  system,  which  was 
clearly  out  of  order.  His  tongue  was  furred  and  flabby,  taking 
the  marks  of  the  teeth ;  his  bowels  were  costive  ;  his  pulse 
was  68,  and  good  ;  liis  morning  temperature  was  97°,  and  the 
evening  96°"8.  He  was  put  on  strychnine  in  ^^  grain  doses 
and  quinine,  and  he  affirmed  that  the  strychnine  did  him 
good,  that  he  felt  consciously  the  better  for  it,  that  it  pulled 
Mm  up,  and  enabled  him  to  exercise  more  inhibition  over  Ms 
actions,  and  he  certainly  could  tell  when  it  was  omitted  from 
his  mixture.  He  was  sent  to  walk  all  about  into  town  and 
into  the  country,  and  though  he  often  referred  to  suicide,  it 
was  assumed  in  Ms  case  that  there  was  no  real  danger.  One 
day  he  returned  from  a  walk  alone  in  a  most  excited  state. 


STATES   OF   MENTAL  DEPRESSION.  53 

He  said  he  had  attempted  suicide,  and  disgraced  himself  for 
Hfe.  It  appeared  he  had  come  upon  a  flagstaff  and  had  taken 
one  end  of  the  rope  and  tied  it  round  his  neck,  and  had  then 
taken  the  other  in  his  hand  and  attempted  to  hoist  himself  up 
the  stafi"!  But  there  was  no  mark.  Another  day  he  lay 
down  in  a  ditch  with  a  little  mud  at  the  bottom,  and  said  he 
had  tried  to  drown  himself,  coming  home  with  his  clothes  all 
wet.  In  fact,  there  was  always  an  element  of  the  ludicrous 
in  his  misery  and  in  his  mode  of  expressing  it.  Regarding 
the  suicidal  eiforts  and  expressions  of  hypochondriacal  melan- 
cholies, though  there  is  little  real  risk,  yet  there  is  some.  A 
doctor  patient  of  mine  once  took  a  poisonous  dose  of  morphia 
— doctors  always  poison  themselves  when  they  want  to 
commit  suicide,  just  as  soldiers  always  shoot  themselves — and 
nearly  died.  When  A.  L.'s  mind  could  be  distracted,  and  he 
could  be  got  to  talk  of  anything  but  his  own  bad  feelings,  he 
was  rational,  intelligent,  and  his  memory  good, — this,  too, 
being  characteristic  of  such  patients.  He  got  various  tonics 
along  with  the  strychnine, — viz.,  iron,  arsenic,  vegetable  bitters, 
the  phosphates, — but  my  own  impression  is  that  the  strychnine 
did  him  most  good. 

In  three  and  a  half  months  he  was  so  far  improved  that  he 
believed  he  was  to  get  well  ultimately,  and  tliis  in  a  melan- 
cholic case  is  one  of  the  first  and  one  of  the  surest  signs  of 
commencing  recovery.  He  had  gained  a  stone  in  weight.  He 
could  divert  his  attention  more  easily  from  himself.  His 
mental  pain  was  less,  his  irritability  greater,  and  his  head  felt 
better.  He  lost  the  worst  of  his  extravagant  delusions  first, 
viz.,  that  he  would  be  hanged  for  hurting  his  wife.  By  the 
way,  he  had,  what  I  have  often  noticed  in  such  cases,  exalted 
ideas  of  the  beauty  and  high  qualities  of  his  wife  and  his 
children,  and  the  greatness  of  his  previous  position  and 
prospects,  all  by  way  of  contrast  to  his  own  misery  and  mis- 
deeds. In  six  months  he  was  quite  well,  and  soon  was  able 
for  hard  work,  which  he  did  as  well  as  ever,  being  able  to 
make  a  large  income. 


54  STATES   OF   MENTAL  DEPEESSION. 

jSTo'n',  the  public  and  the  friends  of  patients  are  very  apt 
indeed  to  speak  of  such  cases  and  treat  them  as  if  it  was  all 
the  patients'  fault,  as  if  by  a  voluntary  effort  they  could  throw 
off  such  fooHsh  fancies.  One  hears  even  doctors  talking  in  the 
same  way.  They  do  not  appear  to  understand  how  anyone 
can  believe  such  manifest,  and  what  appears  to  them  childish, 
nonsense  about  the  state  of  the  health  and  organs,  and  yet  be 
reasonable  otherwise.  I  need  hardly  say  how  absurd  such  a 
view  of  the  matter  is.  The  two  cases  I  have  related  show 
how  such  a  condition  is  a  real  disease,  beginning,  running  its 
course,  and  ending  hke  many  other  diseases.  The  physio- 
logical view  to  take  of  such  cases  is,  that  in  them  we  have 
the  brain  centres  that  preside  over  the  great  organic  functions 
of  alimentation  and  generation,  &c.,  disturbed.  When  those 
functions  are  normal  and  the  brain  is  normal,  the  subjective 
f eehng  is  one  of  rest  and  satisfaction — one  of  organic  pleasure. 
When  the  functions  of  those  organs  are  interfered  with,  or 
have  disease  in  them,  we  have  a  feeling  of  organic  pain,  but 
if  our  convolutions  are  in  good  order  we  do  not  put  a  wrong 
interpretation  on  the  pain.  When  the  brain  centres  that  pre- 
side over  those  functions  are  affected  by  a  disease-storm,  then, 
whether  there  is  disease  in  the  organs  or  not,  there  is  often 
sensible  disorder  or  lessening  of  function  (as  when  the  sexual 
appetite  was  paralysed  in  A.  L.),  and  the  performance  of 
function  gives  no  sensible  organic  satisfaction.  If  the  intel- 
lectual centres  are  also  affected,  we  have  the  ill-being  and 
pain  misinterpreted  and  attributed  to  disease. 

All  cases  of  hypochondriacal  melancholia  do  not  recover  as 
those  two  did.  My  experience  has  been  that  this  kind  of 
case,  when  it  occurs  at  the  more  advanced  ages,  is  apt  to  be 
permanent,  or  the  prelude  to  senile  dementia.  I  had  a  medical 
man  (A.  j\I.)  once  under  my  care,  who  was  sixty,  and  who  had 
exactly  the  feelings  I  have  described,  but  who  had  no  motor 
excitement,  who  would  speak  in  the  calmest  manner  possible 
about  his  feelings.  He  said  that  eating,  though  he  had  an 
appetite,    gave  liim  no   pleasure  ;    that   he  had  no  sense  of 


STATES   OF   MENTAL   DEPRESSION.  55 

repletion,  so  that  lie  had  to  stop,  not  because  he  felt  he  had 
eaten  enough,  but  because  he  saw  he  had  eaten  enough.  He 
said  that  he  had  no  comfortable  satisfaction  after  his  bowels 
were  moved ;  that  he  had  no  sexual  desire  or  power  what- 
soever, which  was  true.  He  never  recovered,  and  he  never 
could  be  made  fat,  though  every  physiological  and  therapeutic 
f attener  was  tried.  He  said  he  felt  all  the  time  as  if  he  had 
a  "paralysis  of  the  sympathetic"  in  his  abdomen.  It  was  he 
who  tried  to  poison  himself  with  morphia ;  and  he  did  at  last 
commit  suicide  after  hving  twelve  years  quietly,  and  at  times 
almost  happily,  on  a  farm  in  the  country.  Certainly  the  cases 
who  affirm  they  have  no  stomachs  nor  gullets,  and  that  their 
bowels  are  not  moved  for  years,  &c.,  must  have  the  subjective 
feeling  somewhat  the  same  as  they  would  have  if  those  things 
were  so.  I  have  seen  male  senile  hypochondriacs  get  very 
erotic  mentally,  with  no  sexual  power.  They  would  want 
female  nurses  about  them,  would  have  them  wash  and  meddle 
with  their  organs  of  generation,  would  wet  and  dirty  the  bed 
in  order  to  be  washed  by  a  female  nurse,  have  enemata  ad- 
ministered, while  all  this  time  they  would  affirm  that  they  had 
no  stomach,  that  they  could  take  no  food,  that  their  bowels 
were  never  moved,  and  that  they  were  so  weak  that  every 
movement  was  an  intense  pain. 

That  hypochondriacal  delusions  are  determined  at  times 
by  peripheral  organic  disease  is,  I  think,  sufficiently  proved 
by  pathological  evidence.  Many  cases  of  hypochondriacal 
melanchoHa  are  caused  by  want  of  work,  by  want  of  rational 
interest  in  life,  by  sluggishness  of  mind,  by  selfish  indulgences 
such  as  well-off  old  bachelors  practise,  by  over-eating  and 
little  exercise,  by  too  routine  modes  of  work  and  living.  For 
these  the  treatment  must  be  work  and  activity  and  change. 
I  knew  such  a  man  cured  by  losing  his  fortune  and  having  to 
work  hard  for  his  living,  and  a  woman  cured  by  marrying  a 
poor  widower  with  seven  children.  I  have  known  a  mother 
cured  by  losing  a  child.  In  fact,  every  variety  of  melancholia 
is  often  cured  by  a  great  domestic  loss,  a  real  grief  taking 


56  STATES   OF   MENTAL   DEPEESSION. 

the  place  of,  and  driving  out,  the  morhid  mental  pain ;  but 
before  this  can  occur  the  general  nutrition  must  usually  be 
improved. 

There  is,  of  course,  no  dividing  hne  between  the  hypo- 
chondriacal variety  of  melanchoHa  and  any  other  form. 
Especially  it  runs  into  that  variety  that  I  have  called 
delusional  melanchoha,  of  wliich,  in  fact,  it  may  be  regarded 
as  a  less  severe  variety.  When  the  delusions  in  that  form 
refer  to  the  bodily  organs  or  the  patient's  health,  it  is  difficult 
in  some  cases  to  say  whether  the  word  "  hypochondriacal " 
apphes  or  not. 

Deludonal  Melancliolia. — By  this  term  I  do  not  mean 
simply  melanchoha  with  delusions.  In  that  case  nearly  all 
melanchohc  patients  would  come  under  this  class.  I  mean 
by  it  that  variety  of  the  disease  in  which  delusions,  or  a 
delusion,  are  from  the  beginning  the  most  prominent  mental 
symptom,  in  which  those  delusions  remain  throughout  the 
disease  of  the  same  character,  being  what  are  called  "  fixed 
delusions,"  in  contradistinction  to  delusions  that  change  in 
kind,  or  subject,  or  degree.  As  a  general  rule,  in  this 
variety  of  melancholia  the  delusion  stands  out  so  that  the 
friends  of  the  patient  call  it  the  cause  of  his  disease,  and  say 
that  if  he  could  get  rid  of  it  he  would  be  all  right.  It  is  the 
peg  on  which  all  the  mental  pain  and  depression  seem  to 
hang.  To  those  who  do  not  consider  the  nature  of  the 
disease,  the  delusion  seems  the  primary  and  causal  event,  the 
depression  the  secondary  and  resulting,  just  as,  when  a 
prosperously  happy  man  loses  his  wife  and  becomes  sad,  his 
loss  is  the  cause  of  his  grief.  In  some  cases  this  may  be  so, 
but  in  by  far  the  majority  of  them  the  delusion  and  the 
depression  are  both  results  of  the  same  cause,  viz.,  disorde*r 
of  the  brain,  that  being  commonly  developed  out  of  hereditary 
tendency,  and  excited  into  action  by  peripheral  disease  in 
some  other  part  of  the  body,  by  blood-poisoning,  or  by 
unphysiological  modes  or  conditions  of  hfe.  The  relation 
of  emotion  to  delusions  and  "  fixed  ideas  "  in  insanity  on  the 


STATES   OF   MENTAL   DEPEESSION.  57 

borderland  conditions  is  much  the  same  as  emotion  to  trains 
of  thought  and  imagination  in  health.  Sometimes  this 
emotion  arises  out  of  the  ideas  before  the  mind,  and  some- 
times the  ideas  originate  emotional  states.  Melancholia 
being  more  essentially  an  emotional  disorder  than  any  other 
form  of  insanity,  the  depressed  feeling  frequently  causes 
melancholic  delusions. 

The  delusions  of  melanchoHcs  are  almost  infinite  in  number 
and  variety.  I  have  had  the  chief  delusions  of  about  one 
hundred  put  down,  just  as  they  were  expressed  to  me  (see 
p.  79).  A  sadder  list  of  the  causes  of  human  misery,  if  they 
were  real,  it  would  not  be  easy  to  find.  To  the  unfortunate 
men  and  women  who  hold  these  behefs  they  are  as  real  as  if 
they  had  been  true.  They  are  enough  to  furnish  another 
Dante  with  the  causes  of  torture  for  another  Inferno.  It  is 
true  they  were  not  all  fixed  delusions  of  the  delusional 
variety  of  melancholia.  To  give  a  right  idea  of  that  form  of 
disease  I  shall  classify  the  delusions  somewhat,  and  give  one 
or  two  cases  representing  each  kind.  The  first  kind  of  case 
I  shall  speak  of  is  that  most  nearly  allied  to  the  hypochon- 
driacal last  described,  where  the  delusions  refer  to  the 
patient's  body  or  health,  or  to  the  performance  of  the  bodily 
functions.  These  are  very  interesting  from  the  physician's 
and  the  physiologist's  point  of  view,  for  the  one  expects  that 
by  curing  any  bodily  disease  present  he  will  cure  the  de- 
lusion ;  and  the  other  finds  in  such  a  connection  of  special 
mental  disturbance  with  special  bodily  disorder  a  sure  proof 
of  the  relationship  between  certain  parts  of  the  brain  and 
the  organs  of  the  body.  !N"ot  that  we  can  in  all  cases 
demonstrate  during  life  or  after  death  such  a  direct  con- 
nection. 

There  is  a  very  common  kind  of  case  where  the  delusions 
refer  to  the  stomach  and  bowels  ;  I  call  them  the  visceral  or 
abdominal  melancholies.  "While  they  may  be  regarded  as 
having  something  in  common  with  the  hypochondriacal  cases 
described,    yet   they   are   of   a   far   more   serious   character. 


58  STATES   OF  MENTAL  DEPRESSION. 

Their   delusions   are   more   intensely   believed   in,    and    the 
mental  depression  is  much  more  profound.     There  are  not 
only  suicidal  feelings  and  expressions,  hut  serious  attempts  in 
many  cases.     The  organic   functions   and  appetites   are  far 
more  interfered  with.     The  appetite  for   food  is  paralysed, 
and  nourishment  is  resolutely  refused.     The  sense  of  organic 
satisfaction  in  eating,   digestion,   and  alimentation  generally 
is  changed  to  one  of  uneasiness  or  pain.     The  patients  thus 
get  wasted.     Sometimes  real  pain  is  felt   in   the   abdomen. 
Many   of    them   complain   of    an    intense    sinking    at    the 
epigastrium,    very   like   that   which    combined   hunger    and 
fatigue  produce  in  healthy  persons.      Some   complain   of  a 
constant  fulness  in  the  abdomen,   others  of  the  disagreeable 
feeling  that  costiveness  produces,  others  of  a  constant  sensa- 
tion of  irritation,  emptiness,  and  faintness.     The  fancies  and 
delusions  attached  to,  and  arising  out  of,  those  real  sensations 
are  most  various,  as  may  be  seen  by  referring  to  the  list  of 
melancholic  delusions  I  shall  give  (see  p.  79).     All  exaggerate 
their  costiveness  or  looseness,  as  the  case  may  be.     All  say 
their  food  does  and  will  do  them  no  good.     They  are  so  far 
right  that,  put  as  much  food  as  you  Hke  into  their  stomachs, 
it  does   not  nourish  as  in  health.     Some  say  they  have  no 
stomachs,  some  no  gullets.     All  say  that  the  food  will  not 
digest.     Some  say  they  have  foul  breaths  and  smells  from 
their  bodies  that  make  them  offensive  to  those  about  them. 
Some    say  that    they   have    syphilis ;    some   that    they   are 
being  poisoned — indeed  this  is  common  ;  some  that  the  devil, 
or  mice,  or  rats,  or  cats  are  inside  them.     The  sense  of  taste 
is  certainly  perverted  in  many  of  the  cases,  so  that  food  tastes 
badly. 

All  take  food  without  enjoyment  of  it.  Some  take  it  only 
because  they  know  they  will  be  forced  to  do  so  if  they 
refuse  ;  while  others  resist  every  persuasion,  and  have  to  be 
fed  forcibly  by  means  of  tubes  passed  into  the  gullet  or 
stomach.  They  are  mostly  thin  and  sallow,  and  some  of 
them  die  of  starvation  with  plenty  of  food  in  their  stomachs. 


STATES   OF   MENTAL   DEPRESSION.  59 

In  some  of  the  older  cases  there  is  a  tendency  to  alternate 
constipation  and  obstinate  diarrhoea. 

I  had  under  my  care  in  the  Carlisle  Asylum  two  very 
interesting  cases  (brothers),  both  of  whom  were  cases  of 
visceral  melancholia,  and  became  insane  about  the  same  age, 
and  both  of  lohom  had  the  same  delusions,  viz.,  that  their 
bowels  were  obstructed,  and  in  both  organic  disease  loas  found 
after  death  in  the  visceral  tract.  Dr  Campbell  published  an 
account  of  them,^  of  which  this  is  an  abstract  : — 

A.  N.  Admitted  into  the  Carhsle  Asylum  on  February 
16,  1865.     Male;    60  years  of  age. 

No  hereditary  predisposition  existed  as  far  as  could  be 
ascertained,  and  this  was  the  first  attack  of  insanity. 
Mentally,  he  had,  at  the  outset  of  the  attack,  been  very  dull 
and  very  hypochondriacal  in  his  fancies.  His  bodily  health 
had  been  tolerably  good.  He  had  been  impulsively  dangerous ; 
but  had  not  attempted  or  threatened  suicide.  On  admission 
he  was  found  to  be  above  the  average  height,  well  built, 
and  in  fair  bodily  health.  Mentally  he  was  very  dull  and 
desponding.  His  memory  was  good.  He  could  speak 
coherently  and  answer  questions  correctly,  but  could  not 
carry  on  a  conversation  owing  to  his  always  recurring  to  his 
bodily  condition,  which  he  described  thus  :  that  his  belly  was 
so  much  swollen  that  he  could  not  take  any  food ;  that  he 
never  got  anything  through  him  ;  and  that  when  he  took 
castor  oil  it  came  away  without  moving  his  bowels.  Nothing 
unusual  could  be  discovered  in  the  state  of  his  abdominal 
viscera.  He  refused  his  food  for  three  days,  and  had  to  be 
fed  once  with  the  stomach  pump. 

Little  change  is  reported  to  have  taken  place  in  the  mental 
or  physical  state  of  the  patient  for  two  years  and  a  half, 
when  he  had  again  on  several  occasions  to  be  fed  with  tube, 
owing  to  his  persistent  starvation  on  the  ground  that  his 
intestines  were  full.  He  was  most  miserable  in  mind, 
frequently  contemplated  committing  suicide,  and  at  least  on 
^  Jour.  Ment,  Science,  Jan.  1875. 


60  STATES   OF   MENTAL   DEPRESSION. 

one  occasion  attempted  to  strangle  himself.  He  went  about 
the  wards  shouting  that  he  had  "  forty  days'  meat  in  his 
belly,"  that  he  was  "bunged  up,"  &c. ;  and,  if  permitted, 
would  spend  most  of  the  day  in  the  water-closet.  A  dose  of 
medicine  always  produced  an  alvine  evacuation  of  normal 
colour.  During  this  year  both  his  ears  became  shghtly 
swollen  (the  insane  ear),  then  shrank,  and  became  much 
misshapen. 

On  October  16,  1874,  having  gradually  got  weaker, 
without  any  marked  symptom  or  any  special  disease,  he  died. 
Almost  his  last  words  were  that  he  had  forty  days'  meat  in 
liis  belly. 

Autoxjsy. — Head. — There  was  an  abnormally  large  amount 
of  fluid  under  the  membranes,  and  the  convolutions  were 
considerably  atrophied.  Sections  of  brain  showed  it  to  be 
rather  softer  than  normal.  Sufficiently  rich  in  puncta  in 
some  parts ;  at  base  of  brain  it  presented  a  slightly  reticulated 
appearance  from  atrophy  round  minute  vessels.  The  floors 
of  the  lateral  ventricles  were  studded  with  small  granulations. 
Chest. — In  the  lower  lobe  of  the  left  lung,  at  its  outer 
surface,  there  was  a  large  vomica  containing  dark  grumous 
fluid,  and  on  the  pleural  coat  of  the  lung  there  was,  outside 
the  cavity,  some  deposit  of  grey  tubercle.  Abdomen. — Liver 
normal ;  duct  from  gall  bladder  and  pancreas  patent.  The 
gall  bladder  contained  a  considerable  amount  of  thin  bile. 
Stomach  normal  —  contained  some  food ;  small  intestine 
normal  through  its  course ;  large  intestine  contained  a  con- 
siderable amount  of  rather  hard  yeUow  f^ces.  The  large 
intestine,  50  inches  from  the  caput  caecum,  and  2|  inches 
above  the  sigmoid  flexure,  had  a  very  constricted  part  3 
inches  in  extent,  and  yo-ths  of  an  inch  in  diameter.  Above 
the  stricture  the  gut  was  2  inches  in  diameter.  The  portion 
of  gut  below  this  to  the  anus  was  normal  in  cahbre. 

A.  0.  Admitted  June  22,  1868,  set.  61.  No  other  heredi- 
tary predisposition  as  far  as  known,  except  that  he  is  a 
brother  of  A.  X.     Xo  cause  could  be  assigned  for  the  attack. 


STATES   OF   MENTAL   DEPRESSION.  61 

He  is  stated  to  have  been  insane  for  two  months  ;  previously 
he  had  been  a  steady,  hard-working  man.  The  first  mental 
symptoms  noticed  were  great  dulness  and  hypochondriacal 
fancies ;  latterly  he  had  become  worse — very  melanchoHc  and 
suicidal.  He  complained  much  of  abdominal  discomfort, 
indigestion,  and  costiveness.  On  admission  he  was  found  to 
be  a  middle-sized  man,  old-looking  for  his  age ;  his  tongue 
clean.  Temperature  97°.  Pulse  60.  Skin  and  conjunctivae 
slightly  tinged  yellow.  Bronchitic  rales  heard  over  both 
lungs.  Abdominal  viscera  seemed  normal.  Mentally  was 
very  dull  and  miserable,  wringing  his  hands,  complaining  that 
he  can  get  "nothing  through  him,"  that  his  "belly  is  much 
swollen,"  wishing  liimself  dead,  saying  that  he  should  be 
hanged,  &c. 

Patient  continued  miserable  and  dull  after  admission ;  if 
permitted,  would  spend  most  of  the  day  on  the  water-closet, 
trying  to  defsecate,  and,  even  after  his  bowels  had  been 
cleared  out  by  the  action  of  medicine,  persists  that  they  are 
full,  that  he  needs  medicine,  and,  though  not  so  noisy  as  his 
brother,  goes  about  complaining,  in  almost  the  same  words, 
that  he  is  "  bunged  up,"  &c. 

.  He  continued  in  the  wretched  mental  state  described  for 
a  year  and  a  half.  He  had  been  treated  vntli  vegetable 
tonics  and  blue  pill,  frequently  repeated,  as  it  had  been 
noticed  that  his  stools  were  clay-coloured ;  and,  as  his  bowels 
were  very  costive,  aperient  medicine  had  been  given  to  liim  at 
intervals.     He  sank  and  died  on  iN'ovember  2,  1869. 

Autopsy. — Head. — The  whole  brain  was  very  oedematous. 
Fornix  almost  diffluent,  and  corpus  callosum  of  both  sides 
extremely  soft.  The  optic  thalamus  of  the  left  side  was  in  a 
more  softened  state  than  the  right.  The  cerebellum  was 
abnormally  soft  and  oedematous.  Chest. — The  lower  portion 
of  the  right  lung  was  much  congested,  and  contained 
innumerable  small  points  of  tubercular  deposit.  The  lower 
lobe  of  the  left  lung  was  congested,  and  fuU  of  minute  points 
of  tubercular  deposit ;  its  upper  lobe  was  slightly  congested, 


62  STATES   OF   MENTAL   DEPRESSION. 

and  contained  a  few  deposits  of  tubercle.  Abdomen. — Liver 
sliglitly  dark  in  colour,  otherwise  appeared  normal;  gaR 
bladder  very  small  and  shrunken,  its  walls  were  very  much 
thickened,  it  contained  a  httle  black  bile.  The  gall  bladder 
and  pancreas  had  separate  ducts  entering  to  the  duodemim, 
that  from  the  pancreas  entering  lowest.  The  duct  from  the 
gall  bladder  was  not  patent  at  its  termination ;  it  ended  in  a 
cul-de-sac  of  the  intestinal  wall.  The  wall  of  the  intestine 
was  thickened  at  this  part,  and  looked  hke  an  ulcer  inside 
of  the  intestine. 

These  cases  show  that  different  kinds  of  abdominal  distress 
and  disturbed  ahmentation  may  excite  the  same  delusion. 
Extreme  constipation  existed  in  both  cases,  but  from  quite 
different  causes — mechanical  obstruction  in  the  one,  and  lack 
of  bile  in  the  other.  We  know,  of  course,  that  neither 
constipated  bowels,  or  lack  of  bile,  or  mechanical  obstruction 
is  necessarily  followed  by  such  mental  delusions.  For  these 
we  need  something  else,  viz.,  brain  convolutions  predisposed 
to  disordered  action,  which  results  in  a  mental  misinterpre- 
tation of  real  pain  or  organic  discomfort ;  and  in  those  two 
brothers,  though  their  family  history  was  unknown,  that 
cause  of  the  insanity  was  no  doubt  present  in  the  shape  of  a 
hereditary  neurosis.  One  is  justified  in  thinking  that  both 
causes  were  needed  to  produce  the  result  in  those  men,  who 
might  have  died  reputedly  sane  but  for  the  abdominal  diseases 
which  converted  the  heredity  from  a  potentiality  into  an 
actual  disorder.  It  will  be  observed  that  they  both  began  to 
exhibit  symptoms  of  insanity  soon  after  60,  and  the  brain  in 
both  cases  presented  signs  of  organic  degeneration. 

There  is  no  doubt  a  special  tendency  for  abdominal  and 
cardiac  injuries  and  diseases  to  be  accompanied  by  mental 
depression  or  a  sense  of  vague  discomfort. 

The  two  folloioing  are  cases  ichere  an  organic  lesion  was 
found  after  death,  that  had  evidently  determined  the  character 
of  the  delusion  : — 

The  first  was  a  case  of  visceral  melancholia,  beginning  as 


STATES   OF   MENTAL   DEPKESSION.  63 

Simple  melancholia,  then  expressing  religious  delusions,  then 
visceral  delusions  ;  "  no  oesophagus  "  ;  refusal  of  food  ;  forcible 
feeding ;  death ;  intestine  large,  and  scyhala  found  almost 
obstructing  bowel. 

A,  P.,  set.  58.  Disposition  lively,  social,  clieerful.  Habits 
active  and  industrious.  Two  previous  attacks  of  melancholia; 
one  lasted  about  two  years ;  treated  at  home,  and  by  change 
of  residence.  Paternal  aunt  died  insane.  Exciting  cause  not 
known.  First  symptoms :  change  of  disposition  and  habits, 
depression,  inactivity,  apathy,  sleeplessness  (treated  with 
morphia).  Recent  symptoms :  deep  depression,  despair, 
rehgious  delusions,  e.g.,  that  there  was  no  hope  for  her,  that 
she  had  committed  an  unpardonable  sin  ;  restless  ;  sleepless  ; 
no  attempt  at  suicide.     Duration  of  attack  :  two  months. 

On  admission,  great  depression,  taciturnity,  and  delusions 
as  to  her  spiritual  state.  She  was  quite  coherent  and  free 
from  excitement.  Memory  good.  Physical  condition  poor. 
Nervous  system  and  thoracic  and  abdominal  organs  appar- 
ently healthy.  Appetite  good.  She  slept  little  for  nine 
nights,  getting  no  morphia,  and  missing  it  very  much.  Took 
sufficient  food.  Was  quiet,  reserved,  and  depressed ;  thought 
her  case  a  hopeless  one.  Considerable  improvement  occurred 
at  first,  and  then  greater  depression  and  a  change  in  the 
character  of  the  case,  the  delusions  now  assuming  the  visceral 
character.  Became  restless,  excited,  and  intractable.  Said 
she  could  not  hve,  and  tried  to  strangle  herself.  Refused  her 
food  because  she  said  she  had  no  gullet.  Grew  steadily  worse. 
Abdomen  full,  and  a  tumour  was  diagnosed.  Persistently 
refused  food.  Had  to  be  fed  with  nose  tube  thrice  daily, 
and  very  frequently  vomited  the  meal.  Bowels  had  been 
obstinately  constipated ;  laxatives  and  enemata  being  employed 
caused  unformed  evacuations.  Breath  became  extremely 
offensive,  mouth  covered  with  sordes.  Died  six  months  from 
beginning  of  attack,  and  four  months  and  one  week  after 
admission  to  the  Asylum. 

Autopsy. — Beyond  very  slight  atrophy  of  the  grey  matter. 


64  STATES   OF   MENTAL   DEPEESSION. 

there  was  no  apparent  brain  disease.  The  thoracic  and 
abdominal  organs  were  healthy,  with  the  exception  of  the 
intestines.  The  intestinal  walls  were  greatly  distended  at 
different  parts,  the  large  intestine  being  particularly  so 
affected.  In  the  large  intestine  huge  masses  of  hard  faecal 
matter  were  found,  which  must  have  been  there  for  a  con- 
siderable time,  judging  from  their  appearance  and  the  amount 
of  irritation  set  up  in  the  intestinal  walls.  On  several  parts 
of  the  internal  surface  of  the  latter  there  were  considerable 
extravasations  of  blood  and  traces  of  inflammatory  action. 
One  huge  mass  of  faecal  matter  seemed  to  block  up  the  lower 
orifice  of  the  intestinal  canal.  This  case  taught  me  a  lesson 
about  getting  the  bowels  well  cleaned  out  in  all  cases,  and  in 
two  at  least  I  have  treated  since,  recovery  has  followed  the 
evacuation  of  impacted  scybalous  masses. 

Curahility  of  Visceral  Cases. — Fortunately  all  such  cases 
do  not  terminate  in  death,  nor  are  they  all  accompanied  by 
organic  disease  or  obstruction  of  the  viscera.  Most  of  them 
are  incurable,  and  yet  after  death  we  often  find  no  organic 
disease  to  account  for  the  symptoms  during  life.  Indeed, 
this  is  the  case  with  the  greater  number  of  the  typical  cases. 
As  the  result  of  a  statistical  inquiry  into  this  form  of  insanity, 
taking  all  the  cases  I  had  notes  of,  I  arrived  at  the  following 
results :  In  the  first  place,  out  of  the  visceral  cases  only  one- 
fifth  completely  recovered,  a  few  making  a  partial  recovery, 
the  acute  misery  and  the  delusions  passing  off,  but  some 
depression  and  some  enfeeblement  of  mind  remaining.  Of 
those  who  recovered  several  relapsed  into  the  same  mental 
state  at  older  periods  of  life,  and  then  remained  incurable. 
Another  fact  in  regard  to  this  disease  came  out  in  the  statistics, 
viz.,  that  every  typical  case  was  over  fifty  years  of  age. 
Some  of  the  cases,  in  which  there  was  no  organic  disease 
found  after  death,  had  been  characterised  by  a  tendency  to  a 
sort  of  passive  diarrhoea  during  the  later  stages  of  the  disease, 
the  best  cure  for  which  I  always  found  to  be  the  recumbent 
position.     It  seemed  to  be  a  diarrhoea  from  deficient  inner- 


STATES   OF   MENTAL   DEPRESSION.  65 

vation  of  the  boAvels — a  sort  of  alimentary  atony.  This  was 
usually  accompanied  by  tissue  wasting  throughout  the  body, 
a  low  temperature,  an  incapacity  to  resist  cold,  a  blue  el  illy 
state  of  the  extremities,  and  a  tendency  to  congestions, 
tubercles,  and  low  inflammations.  In  fact,  either  such  con- 
ditions seem  the  natural  termination  of  life  in  such  cases,  or 
intercurrent  diseases  engendered  by  those  conditions,  such 
as  bronchitis,  catarrhal  pneumonia,  tuberculosis,  gangrene  of 
lungs,  &c. 

The  following  is  another  very  good  example  of  this  important 
and  troublesome  class  of  cases,  there  being  present  delusional 
melancholia,  caused  hy  exhaustion  from  over-ivork,  the  delusions 
being  that  all  animal  food  given  toas  human  flesh,  and  was 
poison  ;  with  refusal  of  food.  Two  attacks ;  first  recovered 
from  ivitli  perfect  mental  capacity  for  hard  loorh  ;  second  attack 
ending  in  death. 

A.  Q.,  set.  50.  During  liis  first  attack,  which  consisted  of 
mental  depression  and  delusions  that  his  food  was  "  raw 
human  flesh,"  so  that  he  would  not  take  it,  he  lost  over  two 
stone  in  the  two  months  the  disease  had  lasted  before  he  was 
placed  under  treatment  in  the  Asylum.  The  cause  had  been 
mental  anxiety  and  over-work,  and  no  heredity  was  admitted. 
The  strange  fancies  that  "  suggestion  "  will  cause  were  well 
illustrated  by  his  imagining  that  the  arrow  on  the  paper  in 
the  crown  of  his  hat  had  been  put  there  to  indicate  that  he 
would  be  put  in  a  dark  coal-cellar  if  he  did  not  eat  arrowroot ! 
This  is  an  excellent  example  of  that  morbid  suggestion  which 
plays  a  great  part  in  many  forms  of  insanity.  He  also  beheved 
his  food  was  poisoned ;  and  he  would  not  use  the  water-closet, 
as  he  imagined  it  would  interfere  with  the  drainage.  He  had 
cold  hands  and  feet;  liis  skin  was  blue  and  cold;  he  lost  his  big 
toe  nail  from  a  cliilblain  ;  and  he  had  a  boil  on  his  face.  He 
pointed  to  all  these  tilings  in  proof  of  the  truth  of  his  delusion 
that  he  had  been  poisoned.  He  had  oxaluria,  and  Ms  bowels 
were  costive.  He  was  fed  well,  got  stimulants  and  fresh  air, 
and  gained  in  weight ;  but  in  seven  months  from  the  beginning 

E 


66  STATES   OF  MENTAL  DEPEESSIOX. 

of  his  illness  lie  would  still  take  no  interest  in  anything  but 
the  state  of  his  howels.  In  ahout  a  year  from  the  beginning 
of  his  iUness  he  had  recovered  from  his  depression,  and  had  got 
rid  of  his  delusions,  and  he  was  strong  and  stout.  In  eighteen 
months  he  was  doing  an  enormous  professional  business, 
implying  the  greatest  mental  strain  and  the  exercise  of  the 
highest  intellectual  abihty.  He  did  so  for  eight  years,  and 
then  the  symptoms,  mental  and  bodily,  that  I  have  described 
came  on  again,  and  he  had  again  to  be  placed  under  treatment 
in  the  Asylum.  This  time  he  was  over  60.  He  was  more 
emaciated  ;  he  showed  marked  signs  of  arterial  degeneration  ; 
his  prostate  was  enlarged,  and  his  urine  troubled  him  both  by 
retention  and  incontinence  at  different  times  ;  he  was  scarcely 
able  to  speak  above  a  whisper  ;  and  in  his  gait,  attitude,  and 
movements  he  gave  the  impression  of  an  old  man.  In  spite 
of  every  treatment — tonic,  nerve-stimulant,  fattening,  and 
stimulant — he  grew  worse.  He  was  compelled  to  take  enough 
food,  but  it  did  not  fatten  him.  He  was  constantly  troubled 
with  a  mild  diarrhoea,  and  he  could  not  always  keep  himself 
clean,  "Whenever  in  any  form  of  insanity  the  patient  persist- 
ently passes  urine,  or,  worse  still,  faeces,  in  his  clothes  or  bed^ 
it  is  a  bad  sign  on  the  whole.  It  appears  to  imply  always  a 
profoundly  diseased  interference  with  the  radical  instincts  of 
man.  The  chief  exceptions  to  this  bad  prognosis  from  this 
cause  are  when  it  happens  in  very  weak  persons,  in  acute 
deUrious  mania,  and  in  stupor.  The  patient  was  removed 
home,  and  gradually  sank  in  about  nine  months  from  the 
beginning  of  his  second  attack  (see  Plate  XIII.,  fig.  6). 

I  lately  was  consulted  about  a  similar  ease  that  recovered. 
A  lady,  A.  Q.  A.,  set.  67,  had  an  attack  of  jaundice,  followed 
by  melancholia,  eight  years  ago.  The  depression  lasted  for 
four  years,  but  complete  recovery  took  place.  After  keeping 
well  for  three  years,  she  took  nephritis  and  congestion  of  the 
hver,  and  the  melancholic  symptoms  at  once  returned  in  a 
more  severe  and  ^'isceral  form.  She  refused  food,  and  had 
delusions   that   she  could   not   swallow,  and   had  a  choking 


STATES   OF   MENTAL   DEPRESSION.  67 

feeling.  She  did  not  sleep,  and  was  then  very  prostrate.  By 
means  of  insistent  and  kindly  nursing  at  home,  daily  liquid 
custards  of  milk  and  eggs,  champagne,  fresh  air,  and  the 
judicious  use  of  paraldehyde  one  night,  chloral  and  very  small 
doses  of  morphia  the  next,  this  alternation  being  kept  up  for 
months,  she  gradually  made  a  good  recovery. 

Such  cases  as  the  last  show  that  the  morbid  brain  action, 
the  trophic  paralysis,  the  actual  visceral  derangement  and  its 
exaggerated  mental  representation,  can  all  be  recovered  from. 
It  also  shows  that  there  is  liability  to  return  with  the  decad- 
ence of  function  and  degeneration  of  tissue  of  advancing  Hfe. 
As  we  shall  see  when  I  come  to  speak  of  the  climacteric  period 
and  its  characteristic  mental  disease,  this  great  physiological 
crisis  has  much  to  do  with  such  a  case,  as  well  as  with  the 
three  preceding.  Medicine,  rest,  food,  fresh  air,  nursing, 
physiological  conditions  of  life  can  do  much,  but  they  cannot 
arrest  the  tendency  to  death  inherent  in  tissue,  and  organ, 
and  organism,  when  their  appointed  time  of  living  has  run. 

If  we  could  connect  the  visceral  delusions  and  depression  in 
every  case  with  visceral  lesions,  as  in  the  cases  of  A.  N.,  A.  0., 
and  A.  P.,  we  should  place  them  in  the  chnical  classification 
as  "  Visceral  Insanity."  As  we  cannot  yet  say  there  is  any 
visceral  lesion  or  disorder  at  all  in  many  of  them,  but  merely 
a  delusion  that  there  is,  I  have  simply  described  the  clinical 
facts  in  regard  to  them,  and  avoided  a  new  "  form  of 
insanity." 

The  following  was  a  complicated  case  of  delusional  melan- 
cholia, with  one  central  and  many  peripheral  causes  of  irritation 
and  exhaustion,  viz.,  a  cancerous  tumour  of  middle  lobe  of  brain, 
disease  of  kidneys,  liver,  pylorus,  4'c. 

A.  Q.  B.,  set.  58,  a  lady  of  good  education,  cheerful  and 
frank  disposition,  domestic  and  industrious  habits,  who  had 
enjoyed  good  health,  and  had  a  family  of  several  children. 
Temperament  not  nervous.  No  hereditary  predisposition  to 
insanity.  Predisposing  cause  of  attack  seemed  to  be  domestic 
anxiety  and  a  sudden  alarm  of  fire.     Had  been  falling  off  in 


68  STATES   OF   MENTAL  DEPEESSION. 

fiesli,  appetite,  and  strength,  tefore  mental  attack,  lout  only 
became  depressed  for  some  weeks  before  admission,  and  soon 
became  possessed  with  the  delusion  that  she  was  very  wicked, 
that  she  had  syphilis,  and  would  infect  those  around  her.  She 
refused  food,  was  sleepless,  and  imagined  she  had  no  passage 
in  her  bowels. 

On  admission  there  was  extreme  depression ;  says  she  is 
very  wicked,  is  lost,  has  syphiHs,  and  is  not  fit  to  be  here. 
Has  an  anxious,  worn,  pinched  expression  of  face.  Cannot 
be  interested  in  anything  outside  herself.  Memory  seems 
fairly  good.  Is  coherent,  and  can  answer  questions ;  very 
thin;  colour  very  bad.  Has  enlargement  of  the  thyroid 
body,  with  prominent  eyeballs.  I^o  paralysis  or  anaesthesia. 
Tongue  slightly  coated.  Bowels  very  costive.  Pulse  88, 
weak.  Temperature,  98° "3.  Patient  was  ordered  a  tonic 
— quinine  and  hydrochloric  acid — and  to  have  two  glasses 
of  sherry  daily,  with  good  nursing,  and  plenty  of  easily 
digested  food  and  fresh  air. 

For  a  time  patient  showed  a  shght  improvement,  but  this 
proved  very  temporary,  and  the  melancholic  condition  became 
aggTavated.  She  slept  badly,  occasionally  having  a  good 
night,  but  generally  being  restless,  with  broken,  disturbed 
sleep.  The  appetite  was  much  impaired,  patient  taking  very 
Httle  food,  and  ultimately  refusing  food  altogether,  so  that 
on  one  occasion  she  had  to  be  fed  with  the  stomach 
pump. 

"With  occasional  slight  variations  from  time  to  time,  patient's 
mental  condition  during  the  winter  continued  much  the  same 
as  that  noted  above  —  depression  and  enfeeblement,  with 
delusions  of  a  melancholic  type.  But  during  all  this  time 
her  physical  health  was  steadUy  deteriorating;  she  took  her 
food  badly,  and  only  with  much  coaxing  (though  the  stomach 
pump  did  not  again  require  to  be  used) ;  she  was  restless  at 
nights ;  the  bowels  were  stni  costive  more  or  less.  There 
was  great  emaciation,  a  shghtly  jaundiced  tint  of  the  con- 
junctiva, and  a  markedly  cachectic  appearance,   such  as  to 


STATES   OF   MENTAL   DEPEESSION.  69 

make  one  suspect  that  the  patient  might  be  lahouring 
under  organic,  and  possibly  mahgnant,  disease.  Great  oede- 
matous  swelling  appeared  in  the  feet,  and  gradually  extended 
up  the  legs.  The  pulse  became  small  and  very  thready,  and 
latterly  could  sometimes  scarcely  be  felt  at  the  wrist.  The 
bowels  at  this  time  were  much  more  regular  than  previously, 
and  the  stools  more  natural  in  appearance.  Patient  grew 
weaker  and  weaker,  and  ultimately  sank,  a  year  after 
admission. 

Autopsy. — Body  much  emaciated.  Brai7i. — Vessels  at  base 
atheromatous.  Vertex  healthy  looking.  There  was  a  tumour, 
the  size  of  a  hen's  egg,  growing  from  the  upper  part  of 
petrous  portion  of  the  left  temporal  bone,  weighing  half  an 
ounce,  and  attached  to  the  inner  table  of  the  bone,  which 
was  someAvhat  softened.  The  tumour  was  encysted  in  the 
brain  matter,  but  not  attached  to  it,  lying  quite  free  in  a 
cup-shaped  cavity.  The  contiguous  brain  substance  was 
flattened  out  and  somewhat  softened. 

.  The  cancerous  mass,  on  microscopic  examination,  was  found 
to  consist  of  small  cells  lying  in  the  meshes  of  a  dehcate 
stroma,  although  much  resembling  brain  matter,  but  dis- 
tinguishable from  it  by  the  absence  of  the  characteristic 
larger  brain  cells  of  the  grey  matter.  The  brain  was  softened 
near  the  tumour,  and  very  aneemic. 

Abdomen. — There  were  several  small  secondary  masses  of 
cancer  at  the  pyloric  end  of  stomach,  the  orifice  of  which 
was  constricted.  No  secondary  cancer  in  liver,  kidneys, 
glands,  or  other  org'nns.  The  splenic  artery  was  enormously 
tortuous  and  dilated.  Liver  was  fatty,  with  thickening  of 
the  coats  of  its  arteries  and  bile  ducts,  and  considerable 
increase  of  fibrous  tissue  round  them.  The  fibrous  tissue 
round  the  bile  ducts  was  deeply  stained  with  bile,  even  to 
the  smallest  duct. 

Kidneys. — Right  kidney  full  of  very  large  cysts,  substance 
otherwise  normal.  Left  kidney  had  marked  cystic  degenera- 
tion.    The  renal  substance  was  almost  gone,  its  place  being 


70  STATES   OF   MENTAL  DEPRESSION. 

taken  by  numbers  of  cysts,  many  of  them  containing  dark 
foetid  fluid  matter. 

I  tbink  one  may  confidently  refer  the  direct  cause  of  the 
special  delusions  in  most  of  tbose  visceral  cases  to  a  disordered 
working  of  that  portion  of  the  brain  wbicb  presides  over  tlie 
function  of  alimentation;  and,  secondarily,  to  a  disordered 
working  of  the  organic  nerve  gangba  that  so  abound  in  tbe 
abdomen — tbe  sympathetic  system  of  nerves,  the  semilunar 
and  visceral  gangha,  and  the  small  nerve  gangha  in  the  coats 
of  the  bowels.  Ferrier  thinks  that  the  posterior  lobes  of 
the  brain  are  the  seat  of  the  organic  brain  functions,  but 
there  is  no  proof  of  this.  The  real  cause  of  the  abohtion  of 
the  normal  food  appetites  in  so  many  diseases  and  states 
of  disordered  health,  and  their  perversion  in  other  instances, 
is  unknown,  but,  beyond  a  doubt,  we  must  refer  many  of 
them  to  some  central  cause  in  the  brain.  The  whole  of 
A.  Q.  B.'s  case  was  interesting  from  there  being  gross  disease 
in  the  brain,  which  probably  caused  the  melanchoha,  and  dis- 
ease in  the  abdominal  viscera,  which  probably  determined  its 
special  character  and  its  delusions. 

In  many  marked  visceral  cases  of  melanchoha,  with  de- 
lusions of  no  stomach  and  intense  repugnance  to  food,  I 
have  had  the  semilunar  and  many  of  the  sympathetic  gangha 
of  the  abdominal  plexus  taken  out,  hardened,  and  cut  into 
sections,  and  examined  them  microscopically,  and  in  almost 
all  cases  I  found  the  nerve  cells  markedly  degenerated, 
atrophied,  and  pigmented  (see  Plate  II.  fig.  5).  Some  of 
the  cells  had  almost  disappeared,  and  very  few  of  them 
in  any  of  the  sections  were  normal.  Beyond  a  doubt  their 
functions  could  not  have  been  properly  performed  by  those 
diseased  cells,  but  whether  tliis  degeneration  was  primary 
or  secondary  to  the  visceral  sensations  I  have  no  means  of 
knowing. 

The  delusions  refer  to  electricity  or  some  such  imaginary 
source  of  annoyance  in  a  large  number  of  instances,  as  in  this 
case,  which  recovered  : — 


STATES   OF  MENTAL  DEPEESSION.  71 

A.  R.,  set.  44 ;  education  average.  Disposition  reserved, 
unsocial,  suspicious,  grasping ;  habits  steady  and  industrious. 
One  previous  attack  of  depression  with  delusions  lasting  a 
month ;  treated  and  cured  by  travel  and  rest ;  no  insanity  in 
family.  Exciting  cause  :  over- work  and  business  anxiety. 
Attack  has  lasted  one  month,  though  he  had  been  dull 
before.  Became  restless  and  sleepless ;  lost  appetite ;  very 
depressed ;  threatened  violence  to  himself ;  was  very  suspicious, 
and  absolutely  possessed  with  the  delusion  that  an  electric 
battery  was  at  work  in  his  house  acting  on  him,  and  causing 
pain  and  sleeplessness.  On  admission,  great  depression  shown 
in  expression,  language,  and  behaviour.  Talks  all  the  time 
about  people  working  on  him  with  an  electric  battery  in  his 
bed,  and  that  enemies  are  conspiring  to  ruin  him.  General 
health  weak ;  condition  poor ;  tongue  foul ;  bowels  costive ; 
conjunctivae  yellow ;  muscles  flabby.  For  a  week  after 
admission  he  remained  extremely  depressed,  reserved,  full 
of  the  battery  delusions,  and  suspicious,  and  slept  very  little. 
Under  light  digestible  food  and  milk,  tonics,  podophylhn 
every  night,  fresh  air,  and  constant  companionship,  he  im- 
proved steadily,  became  more  cheerful  and  sociable,  talked 
less  of  the  delusion,  slept  better,  and  had  a  good  appetite. 
Witliin  three  months  he  was  able  to  hve  in  one  of  the 
detached  houses ;  and  in  two  months  more  he  was  discharged 
recovered,  having  gained  a  stone  and  a  half  in  weight,  looking 
fresh,  and  mentally  quite  happy.  During  recovery  he  passed 
through  the  common  enough  stage  of  behef  in  the  existence 
of  the  battery  at  one  time,  though  he  said  it  was  not  worked 
on  him  then.  After  complete  recovery  he  laughed  at  the 
whole  idea  as  being  a  morbid  fancy ;  but  he  said  his  sensa- 
tions had  been  most  uncomfortable,  that  he  used  to  feel 
sudden  pains,  to  twitch  and  jerk  and  jump  up  in  bed,  and 
had  imagined  those  motor  and  sensory  nervous  symptoms 
meant  that  he  was  worked  on  by  a  battery.  The  pathological 
explanation  of  them  is  no  doubt  this,  that  through  brain 
disorder  or  peripheral  disease,  painful  and  perverted  sensations 


72  STATES   OF   MENTAL  DEPRESSION. 

are  felt,  and  their  meaning  misinterpreted  by  tlie  disordered 
intellectual  centres,  "wliich  are  at  tlie  time  not  in  a  condition 
to  be  affected  by  evidence  or  capable  of  reasoning  riglitly. 
I  once  bad  an  epilej)tic  patient  who,  at  times  after  the 
regular  fits,  used  to  twitch  in  her  Hmbs,  and  who  would 
point  to  the  twitchings  (that  were  evidently  accompanied 
by  pain)  and  say — "'Look  how  it  works  on  me,"  meaning 
that  some  one  was  electrifying  her.  Such  delusions  of 
annoyance  or  being  worked  on  by  electricity,  magnetism, 
or  unseen  agency,  if  they  last  long,  wliile  the  depression 
abates,  are  very  unfavourable  as  regards  prognosis.  But,  so 
long  as  there  is  distinct  depression,  of  which  these  delusions 
are  an  accompaniment,  the  case  should  be  held  to  be  curable, 
and  treated  as  such. 

There  is  a  popular  notion  that  religious  cases  of  melancholia 
are  very  unfavourable.  It  is  meant  that  persons  never  get 
well  who  have  intense  despondency  as  to  their  religious 
condition,  and  delusions  as  to  their  eternal  damnation,  as  to 
having  committed  unpardonable  sins,  having  offended  the 
Holy  Ghost,  having  led  most  wicked  Hves  that  will  never  be 
forgiven,  having  failed  to  instruct  their  children  properly 
in  rehgious  truths,  having  caused  much  sin  in  others  by  their 
example,  having  neglected  the  services  of  rehgion,  having 
been  hypocrites  and  impure  in  heart  and  motive  wliile  pro- 
fessing Christianity,  and  kept  up  rehgious  appearances  so  as 
to  deceive  the  world,  being  possessed  by  the  devil,  &c.  ^o 
doubt  there  are  some  bad  cases  of  rehgious  delusional  melan- 
choha,  and  such  patients  are  apt  to  make  a  strong  impression 
on  those  who  see  them.  In  reference  to  them  the  religious 
superstitions  of  the  Middle  Ages  as  to  diabohc  possession 
still  chng  in  the  popular  mind.  They  are  always  taken  to  the 
clergy  first  for  comfort  and  spiritual  help.  It  is  difficult  to 
draw  the  hne,  too,  between  them  and  the  rehgious  "  con- 
viction of  sin  "  and  the  doubt  and  depression  which,  according 
to  many  systems  of  theological  behef,  are  a  normal  part  of 
the    individual    rehgious    life.      John    Bunyan's   prolonged 


STATES   OF   MENTAL   DEPEESSION.  73 

depression  and  "  darkness,"  and  Carlyle's  "  Stygian  darkness, 
spectre-liaunted,"  his  "  Gehenna  within,"  and  his  "  semi- 
delirium  sad  as  Golgotha,"  are  sufficiently  like  some  of  the 
cases  to  cause  a  feeling  of  confusion  about  them.  Some  of 
the  cases  have  been  called  by  special  names^ — Demonomania, 
&c.  There  is  no  doubt,  too,  that  the  religious  instinct  of  man, 
being  one  of  the  deepest  and  most  central  parts  of  his  psycho- 
logical constitution,  and  one  often  cultivated  and  developed 
from  childhood  in  a  way  that  few  of  his  other  faculties  are, 
causes,  when  it  is  perverted,  intense  general  emotional  disturb- 
ance. These  reasons  are  sufficient  to  account  for  the  general 
idea  that  the  prognosis  in  religious  insanity  is  bad.  But,  as 
a  matter  of  fact,  this  is  untrue.  A  very  large  number  of  cases 
of  melanchoHa  have  a  religious  element  in  them,  and  it 
certainly  does  not  prevent  them  from  getting  better.  The 
following  is  an  example  of  religious  melancholia  : — 

A.  S.,  set.  29.  Disposition  cheerful.  Habits  industrious. 
Comes  of  an  excitable,  eccentric  family.  Causes  of  her  illness 
ill-treatment  by  her  mistress  and  amenorrhoea.  First 
symptoms,  mental  confusion  and  depression,  and  falling  oflf 
in  bodily  looks,  appetite,  and  strength,  and  her  head  feehng 
"  queer."  On  admission  she  had  mental  dej)ression,  as 
indicated  by  her  expression,  attitude,  and  the  general  tone  of 
her  conversation.  There  was  also  slight  mental  enf  eeblement ; 
her  memory  seemed  to  be  greatly  impaired.  She  laboured 
under  various  delusions  of  a  religious  kind,  e.g.,  that  she  v,^as 
the  greatest  sinner  ahve,  and  had  committed  many  and 
unpardonable  sins.  She  wore  a  very  dejected  aspect.  The 
sensory  functions  were  shghtly  dulled,  and  the  reflex  functions 
impaired.  She.  had  suffered  for  several  months  from 
amenorrhoea.  She  was  very  suicidal.  She  was  the  very 
picture  of  misery,  despair,  and  lack  of  interest  in  the  world 
outside  her. 

She  was  put  upon  sulphate  of  quinine,  and  iron,  and  aloes, 
good  food,  and  fresh  air  and  work,  which  she  was  not 
at  first  able  to  settle  herself  to  do.     At  first  there  was  no 


74  STATES   OF  MENTAL   DEPRESSION. 

cliange  for  the  better.  Was  very  depressed  ;  refused  food  ; 
wept  causelessly  at  frequent  intervals,  and  generally  bemoaned 
her  lot  as  being  a  castaway  from  God.  Became  distinctly 
worse  mentally.  Had  hallucinations  of  hearing.  Still 
refused  her  food.  In  two  months  had  greatly  improved  in 
her  mental  and  bodily  condition,  and  took  her  food,  but  was 
at  times  obstinate  and  wayward.  In  five  months  menstruated 
for  the  fijst  time  since  admission,  and  at  once  her  mental 
recovery  was  completed,  and  she  said  she  felt  quite  differently. 
She  had  got  stronger,  stouter,  and  better  looking  before,  but 
the  change  after  menstruation  was  marked  and  immediate. 
The  sense  of  rehgious  depression  and  despair  disappeared,  her 
cheerfulness  returned ;  and  rehgion  thereafter  did  not  trouble 
her  much  one  way  or  the  other. 

In  this  case  she  had  been  brought  up  in  a  rehgious  sect, 
where,  theoretically,  rehgion  was  all  in  aU.  When  she  was 
miserable,  what  would  so  naturally  suggest  the  cause  of  her 
condition  as  the  rehgious  ideas  in  which  she  had  been 
educated  1  But  the  religious  element  in  the  case  in  no  way 
affected  the  progress  or  the  favourable  result  of  the  case. 

There  are  some  cases  of  rehgious  delusional  melanchoha 
where  the  depression  is  certainly  very  intense,  the  mental 
pain  most  deep,  and  the  prognosis  very  bad.  Some  of  those 
are  persons  with  the  combination  of  a  liighly-developed 
rehgious  instinct  and  a  strongly-marked  heredity  to  insanity. 
If,  along  with  those  two  conditions,  life  is  on  the  wane  with 
the  patient,  and  loss  of  weight  and  general  vigour  has  begun, 
and  religions  delusional  melancliolia  then  comes  on,  the  out- 
look is  often  bad.  The  following  is  an  example  of  such  a 
case : — 

A.  T.,  set.  45.  No  children.  No  heredity  to  insanity 
acknowledged  by  relatives,  but  this  I  had  reason  to  doubt. 
Temperament  melanchohc  and  diathesis  nervous,  but  disposi- 
tion had  been  cheerful  and  benevolent ;  habits  active,  especi- 
ally in  doing  good,  teaching  classes  among  the  poor,  and 
comforting  the  afflicted.     A  particularly  bright,  cheery  woman 


STATES   OF  MENTAL  DEPRESSION.  75 

when  well,  and  liappy  in  her  religion.  She  went  to  a  trying 
climate  about  a  year  ago  and  got  a  little  run  down.  A  few 
weeks  before  I  saw  her  she  had  become  dull  and  lost  her 
brightness  and  vivacity.  She  said  she  had  lost  her  "hope  in 
God,"  and  her  comfort  and  assurance  in  religion.  She  thought 
God  had  forsaken  her,  that  she  was  lost,  that  her  former 
rehgious  life  had  been  tinctured  and  polluted  by  selfishness  of 
motive,  and  that  she  had  been  a  hypocrite  before  God  and 
man.  She  would  not  go  to  church,  and  any  attempt  to 
administer  religious  consolation  to  her  in  the  usual  way  by 
clergymen,  engaging  in  religious  exercises  with  friends, 
quoting  suitable  texts,  &c.,  only  made  her  worse.  "  Those 
are  not  for  me,"  she  would  say,  "  I  would  insult  the  Almighty 
more  and  more  by  going  to  church."  Her  mental  pain  and 
intellectual  perversion  entirely  prevented  her  from  being  able 
to  see  the  cheerful  aspects  of  the  Christian  reHgion.  "With 
these  mental  symptoms  there  had  been  headaches  and  strange 
feelings  in  the  head  to  begin  with,  but  these  passed  off,  as  is 
very  common,  when  the  affective  mental  symptoms  developed 
themselves.  But  there  was  a  furred  tongue  that  had  been 
wrongly  treated  by  purgatives.  When  will  our  profession 
fully  understand  that  a  man's  tongue  may  be  as  furred  and 
foul  from  want  of  food,  or  from  an  atonic  innervation  of  the 
stomach  and  bowels,  or  from  a  mere  neurosis,  as  from 
sluggishness  of  the  primcB  vice  ?  She  was  menstruating 
irregularly.  She  looked  haggard  and  flabby.  She  had  lost 
her  feminine  plumpness,  and  her  weight  was  much  less  than 
it  had  been  in  health.  Her  food-appetite  was  paralysed, 
eating  giving  her  no  pleasure.  I  prescribed  nitromuriatic 
acid  and  quinine  mixture ;  fattening  diet,  taken  little  and 
often ;  simple  warm  water  enemata  for  the  bowels ;  change 
of  scene  among  intimate  friends ;  stopped  the  knocking  about 
in  travel  that  she  had  been  trying ;  proscribed  religious  talk 
of  any  sort ;  and  gave  directions  for  her  being  watched  at  all 
times.  But  she  steadily  got  worse,  more  sleepless,  more 
restless  and   agitated,  and  more  miserable,  till  she  was  the 


76  STATES   OF   MENTAL   DEPRESSION. 

picture  of  despair ;  becarae  distinctly  suicidal ;  had  to  be  sent 
to  an  asylum,  and  in  two  years  slie  passed  into  dementia  Avitli 
still  a  melancholic  tinge  to  it,  as  is  usual  in  the  dementia  that 
follows  melanchoha. 

This  case  is  the  common  type  of  rehgious  delusional  melan- 
choha, but  there  are  persons  with  religious  melancholia  of  a 
far  more  subtle  type  than  this — persons  of  a  neurotic  diathesis, 
lively  fancy,  delicate  feeling,  and  keen  religious  sentiment 
that  has  been  developed  by  much  fostering  care  from  their 
youth  up;  persons  who  have  had  many  of  the  functional 
neuroses,  been  martyrs  to  headaches,  varied  by  spinal  irrita- 
tions j  in  torture  from  neuralgia  one  day,  and  roused  by  mild 
hysterics  the  next.  They  are  clergymen's  spinster  daughters, 
or  the  female  members  of  intellectual  and  religious  f amihes. 
They  suffer  much,  but  they  generally  suffer  it  patiently. 
The  depression  of  feeling  with  them  is  usually  hung  on  some 
subtle  controversial  or  doctrinal  peg,  or  on  an  ethical  or 
rehgious  point,  so  fine  that  it  seems  to  a  healthy  mind  almost 
ridiculous  to  regard  it  as  of  any  importance.  Such  persons 
at  times  undergo  temporary  paralysis  of  rehgious  feeling  and 
vohtion,  "  deadnesses,"  and  they  torture  themselves  about  it. 
Those  people  are  all  thin,  and  to  them  I  preach  the  gospel  of 
fatness,  the  gospel  of  fresh  air,  of  healthy  secular  hterature, 
and  active  occupation,  of  iron  and  quinine,  and  a  httle 
bromide  of  potassium  or  paraldehyde  or  sulphonal  when 
needed. 

In  some  cases  of  delusional  melancholia  the  delusions  refer 
to  ridiculously  jpaltry  things.  One  young  man,  A.  T.  A.,  once 
consulted  me  on  account  of  his  depressed  condition,  and  the 
great  depression  under  which  he  laboured  was  caused,  he  said, 
by  his  having  joined  the  Conservative  Club  in  his  native  town 
without  consulting  his  father.  A  woman  hung  her  depression 
on  the  peg  that  the  marriage  ceremony  in  her  case  many  years 
previously  had  not  been  properly  performed  in  some  minute 
particular.  Dozens  of  patients  have  assigned  to  me  as  their 
unpardonable  sin  that  they  had  occasionally  practised  mas- 


STATES   OF   MENTAL  DEPEESSION.  77 

turbation.  Patients  torture  themselves  about  events  in  their 
lives  that  no  one  else  can  see  to  be  of  any  import  whatsoever. 
In  some  cases  the  patients  transfer  their  own  disease  in  delu- 
sional imagination  to  those  near  and  dear  to  them,  and  are 
most  depressed  about  it,  e.g.,  I  have  a  woman  now  who  says 
her  husband  is  very  ill,  that  he  is  "  dull  in  his  mind,  poor 
fellow,  and  I  wish  you  would  cure  him." 
■  The  following  is  a  case  of  delusional  melanGholia,  where  the 
delusions  seemed  at  first  sight  "fixed"  hut  where  recovery  took 
place  satisfactorily : — 

A.  U.,  set.  36.  Disposition  reserved  and  quiet,  but  not 
melancholy.  Nervous  diathesis.  Habits  industrious.  Sister 
incurably  insane,  and  in  an  asylum.  Father  had  an  attack 
of  a  month's  duration.  The  exciting  cause  of  the  attack  had 
appeared  to  be  the  death  of  a  near  relation  of  her  husband, 
whom  she  had  helped  to  nurse.  Tlie  first  mental  symptoms 
were  depression  of  spirits  and  sleeplessness.  She  soon  ex- 
pressed the  insane  delusion  that  she  had  been  the  cause  of  her 
brother-in-law's  death,  through  having  had  improper  thoughts 
and  conduct  towards  him  during  his  life.  This  she  talked  of 
from  morning  till  night,  in  fact  would  speak  of  it  to  strangers, 
and  would  talk  of  nothing  else ;  when  pressed,  her  improper 
conduct  was  found  to  have  consisted  in  smoothing  his  hair 
when  he  was  lying  in  bed  very  ill,  and  even  that  may  not 
have  been  a  fact.  She  would  not  employ  herself,  lost  all 
interest  in  her  work,  or  in  anything.  I  saw  her  in  consulta- 
tion, and  advised  a  good  trained  nurse,  change  and  travel, 
and  visiting  near  relations.  But  she  got  steadily  worse,  and 
was  very  obstinate  indeed,  and  would  take  no  medicine. 
Thinking  that  perhaps  some  uterine  disease  or  disturbance 
might  be  present  and  determine  the  character  of  her  delusions, 
I  wished  her  examined,  but  she  would  on  no  account  consent. 
She  ate  heartily,  and  looked  fat  and  well.  She  made  one  or 
two  futile  attempts  at  suicide  by  twisting  her  hair  round  her 
throat.  When  well,  she  had  been  a  bright  agreeable-looking 
woman;  when  suffering  from  this  illness  her  expression  of 


78  STATES   OF  MENTAL  DEPRESSION. 

face  "was  totally  changed.  One  would  scarcely  have  known 
her  to  he  the  same  person.  This  absolute  change  and  reversal 
of  the  characters  of  the  facial  expression  is  very  marked  in 
such  melanchoHa.  She  had  to  be  sent,  after  about  three 
months,  to  one  of  the  villas  attached  to  the  Asylum,  and  for 
the  first  week  she  did  nothing  but  repeat  her  delusion  and 
fret  about  it ;  she  thought  of  nothing  else.  She  took  up  the 
idea  then  that  she  ought  not  to  have  left  home  or  come  here. 
She  was  sleepless  and  restless  at  night,  and  very  obstinate. 
She  got  tonics,  Hved  in  the  fresh  air,  and  walked  long 
distances  each  day  with  her  attendants ;  ate  well,  and  got 
45  grains  of  bromide  of  potassium  at  night.  She  improved 
for  three  weeks  and  then  had  a  relapse  during  menstruation, 
which  was  abnormally  scanty.  She  felt  as  if  she  had  a  shock 
on  her  head  one  night,  and  after  that  she  felt  as  if  her  brain 
was  "completely  gone."  Such  neuroses  of  sensibihty  are  very 
common  in  and  before  melanchoha,  and  this  feeling  as  if  the 
brain  was  "  gone  "  is  particularly  so.  I  suppose  the  patients 
are  conscious  of  a  mental  incapacity,  a  paralysis  of  thinking 
and  volition,  along  with  a  strange  feeling  in  the  head,  and 
that  this  is  the  foundation  of  this  delusion.  After  this  she 
changed  somewhat.  She  was  more  obstinate  and  very  sleep- 
less, and  unable  to  read  or  employ  herself ;  but,  instead  of 
having  caused  her  brother-in-law's  death,  she  began  to  blame 
herself  for  having  left  home  and  her  husband,  and  harped  on 
tliis  from  morning  till  night,  reproaching  herself  for  what  she 
had  nothing  to  do  with.  I  looked  on  this  change  of  delusion 
as  a  very  good  sign,  and  my  prognosis  was  better  after  that. 
She  menstruated  regularly  but  scantily,  as  she  had  done  from 
the  beginning  of  the  attack.  She  was  put  on  dialysed  iron, 
and  got  it  steadily  thereafter.  In  four  months  there  was  a 
very  great  improvement,  and  in  six  months  she  was  well 
enough  to  go  home,  and  completed  her  recovery  there,  having 
gained  about  a  stone  in  weight  during  her  convalescence, 
though  she  was  never  very  thin  from  the  beginning. 

'Next  to  the  convulsive  and  orstanic  varieties  of  melanchoHa, 


STATES   OF   MENTAL  DEPRESSION. 


79 


the  fixed  delusional  is  on  the  whole  the  least  hopeful  as  regards 
recovery. 

The  following  are  actual  examples  of  delusions  of  about 
100  female  melanchoHc  patients,  and  they  far  from  exhaust 
the  Hst : — 

Delusions  of  general  persecution, 
general  suspicion, 
being  poisoned, 
being  killed, 
being  ruined, 
being  conspired  against, 
being  defrauded. 

being  preached  against  in  church, 
being  pregnant, 
being  destitute, 
being  followed  by  the  police, 
being  very  wicked, 
impending  death, 
impending  calamity, 
the  soul  being  lost, 
having  no  stomach, 
having  no  inside, 
having  a  bone  in  the  throat, 
having  lost  much  money, 
being  unfit  to  live, 
that  she  will  not  recover, 
she  is  to  be  murdered, 
she  is  to  be  boiled  alive, 
she  is  to  be  starved, 
the  flesh  is  boiling, 
the  head  is  severed  from  the  body, 
children  are  burning, 
murders  take  place  around, 
it  is  wrong  to  take  food, 
of  being  in  hell. 
„    being  tempted  of  the  devil. 


80 


STATES    OF  MENTAL   DEPKESSION. 


Delusions  of  being  possessed  of  the  devil. 

having  committed  an  unpardonable  sin. 

unseen  agencies  working. 

her  own  identity. 

being  on  fire. 

having  neither  stomach  nor  brains. 

having  skin  disease  and  infecting  others. 

being  covered  with  vermin. 

letters  being  written  about  her. 

property  being  stolen. 

her  children  being  killed, 

having  committed  theft. 

the  legs  being  made  of  glass. 

having  horns  on  the  head. 

being  chloroformed. 

having  committed  murder. 

fear  of  being  hanged. 

being  called  names  by  persons. 

being  acted  on  by  spirits. 

being  a  man.  .  . 

the  body  being  transformed. 

insects  coming  from  the  body. 

rape  being  practised  on  her. 

having  venereal  disease. 

being  a  fish. 

being  dead. 

having  committed  "suicide  of  the  soul." 


LECTUEE    III. 

STATES    OF    MENTAL    DEPEESSION— MELAN- 
CHOLIA (P^rC^^ZG^Zi)— Continued. 

Excited  {Motor)  M.  :  Restlessness,  noise,  agitation,  wringing  hands, 
moaning,  shouting,  tearing  clothes,  violence,  insane  obstinacy ; 
difficulty  of  management,  hallucinations  ;  Delirium  Tremens  a 
typical  and  exaggerated  variety  of  this  state  ;  muscular  expressions 
of  mental  state  ;  trophic  changes,  boils,  irritations  of  skin  causing 
scratchings,  erosions  of  surface,  pulling  out  hair,  &c. — Resistive 
{Obstinate)  M.  :  Unreasoning  resistance  to  everything ;  trying  and 
difficult  form  to  manage  ;  to  overcome  resistance  forcibly  often 
causes  excitement ;  such  obstinacy  usually  delusional,  with  element 
of  stupor — Convulsive  M.  :  A  rare  but  serious  and  usually  incurable 
form,  with  a  few  attacks  of  severe  convulsions  usually  at  beginning 
of  the  attack  ;  usually  pia  mater  adherent  to  convolutions — Organic 
{Gross  Brain  Disease)  M. :  Occurs  sometimes  in  the  first  stages  of 
organic  brain  diseases  ;  can  usually  be  treated  at  home  ;  seldom 
suicidal — Suicidal  and  Homicidal  M. :  In  every  case  of  Melan- 
cholia, however  mild,  look  out  for  suicide,  and  guard  against  it. 
Meaning  of  suicidal  feeling — infinite  variety  of  motive  and  delusion, 
and  of  modes  of  suicide  ;  concealment ;  cunning  ;  act  depends  much 
on  natural  courage  of  patient,  and  partly  on  his  religious  and  moral 
principles  ;  prevalent  modes  of  suicide  in  individual  cases,  in  nations, 
and  in  sexes  ;  suicide  by  suggestion,  from  seeing  means  at  hand  ; 
subtlety  and  liability  to  recurrence  of  the  impulse.  Homicidal  and 
Suicidal  impulses  and  acts  frequently  combined — Lack  oi post  mortem 
appearances  in  Melancholia  ;  period  of  life  at  which  most  frequent  ; 
hereditary  laws — Treatment :  Diet — tonics,  nutritives,  sedatives  (use 
and  abuse),  stimulants,  quinine,  iron,  strychnia,  phosphorus,  the 
bromides,  mineral  acids,  laxatives,  mineral  waters  ;  fresh  air,  exer- 
cise, baths,  change  of  air,  scene,  and  association,  rest,  travel,  occupa- 
tion, amusement,  music,  avoidance  of  excitement  or  noise  or  strain 
of  any  kind;  many  attacks  will  "run  their  course,"  and  "take 
their  time,"  like  a  fever  ;  nursing,  watching  ;  removal  to  Asylum — 

P 


82  STATES    OF   MENTAL   DEPRESSION. 

Prognosis :  Considerations — youth  ;  general  state  of  body  ;  fixed 
delusions  or  not ;  mode  of  onset  ;  hallucinations  ;  trophic  symp- 
toms in  skin  ;  effect  of  treatment ;  convulsions  ;  suicidal  ten- 
dencies ;  persistent  refusal  of  food.  Hygiene  and  prophylaxis  in 
children  of  melancholic  and  neurotic  families — Diet ;  mode  of  life  ; 
schools  ;  occupations  and  professions  ;  sleep  ;  cramming  and  com- 
petitive examinations. 

Excited  {Motor)  Melancholia. — This,  like  all  the  other  varieties 
of  the  disease,  may  be  one  stage  in  the  complete  chnical 
history  of  a  case,  or  may  he  the  type  from  beginning  to  end. 
The  motor  centres  are  evidently  affected  to  a  greater  extent 
in  this  than  in  any  of  the  other  varieties,  except  the  one  I 
shall  describe  as  the  melanchoha  with  epileptiform  attacks. 
The  patients  rush  about,  are  violent  to  those  about  them, 
wander  ceaselessly,  walk  up  and  down  hke  tigers  in  a  cage, 
or  roll  about  on  the  floor,  bite  their  finger-nails,  or  wring 
their  hands,  or  shout,  or  groan,  or  moan,  or  weep  loudly,  or 
tear  their  clothes,  and  in  all  their  attitudes  and  motions  ex- 
press strongly  their  mental  pain.  In  short,  the  muscular 
expressions  of  the  pervading  emotion  are  strong  and  uncon- 
trollable by  voHtion.  Some  of  the  very  worst  and  most 
incurable  cases  of  melanchoha  are  of  this  type — certainly  the 
most  troublesome  to  manage.  The  motor  expressions  are 
partly  determined  by  the  intensity  of  the  disease  in  the  brain 
centres,  and  partly  by  the  amount  of  inhibition  possessed  by 
the  individual  when  well.  It  must  be  remembered  that  active 
motor  acts  done  when  the  patient  either  "loses  control  over 
himself,"  or  does  not  exercise  that  control,  often  give  sensible 
rehef  to  the  mental  depression,  just  as  shouting,  weeping,  or 
rushing  about  will  give  rehef  to  bodily  pain.  In  such  a  case 
the  nerve-storm  is  "irradiated,"  as  Meynert  says,  into  other 
centres,  and  not  inhibited  so  strongly  as  before.  It  is  not 
uncommon  to  see  cases  of  melanchoha  with  symptoms  that 
closely  resemble  convulsions.  All  the  people  about  the 
patient  say  she  is  in  "  a  fit "  ;  but  it  is  not  a  true  convulsion. 
Women  very  frequently  present  the  motor  type  of  the 
disease.     The  Celtic   race   does  so  markedly.     The   wailing 


STATES   OF   MENTAL   DEPKESSION.  83 

and  weeping,  the  gesticulations  and  motor  grief  of  an  Irish- 
woman are  usually  out  of  all  proportion  to  the  mental  pain — 
that  is,  if  we  take  the  Teutonic  type  as  our  standard.  Here 
is  an  example  of  excited  melancholia  : — 

A.  Y.,  set.  28,  an  Irishwoman.  Patient  had  been  confined 
a  week  previous  to  admission.  The  day  before  her  admission 
she  suddenly  became  very  unsettled  and  careless  about  her 
child ;  she  also  attempted  suicide.  On  admission  she  was 
greatly  depressed;  she  confessed  to  feeling  exceedingly 
miserable,  and  could  be  got  "to  answer  the  simplest  questions 
only  Avith  difficulty ;  she  had  a  woe-begone  appearance,  and 
her  bodily  health  was  very  weak.  She  slept  very  httle  the 
first  night,  but  seemed  considerably  better  next  day  ;  con- 
versed readily  and  cheerfully ;  said  she  felt  much  better,  and 
that  her  strange  behaviour  previous  to  admission  was  due  to 
something  which  came  over  her  and  confused  her. 

In  a  week  she  got  worse,  being  much  depressed ;  thought 
she  was  to  be  kiUed ;  and  that  everything  was  going  wrong 
with  her ;  did  not  take  her  food  well ;  attempted  to  drown 
herself  by  jumping  into   the  Asylum  shallow  curling  pond. 

In  a  month  she  was  somewhat  improved,  but  still  con- 
tinued much  depressed  in  mind.  She  did  a  little  work.  In 
six  weeks,  after  seeming  to  improve  for  a  time,  patient 
relapsed.  She  became  the  embodiment  of  utter  misery  and 
wretchedness,  which  she  exhibited  in  a  most  demonstrative 
way.  She  wrings  her  hands ;  sways  backwards  and  forwards, 
contorting  her  body ;  rushes  about  from  place  to  place,  and 
cannot  settle  for  a  minute.  But  the  most  striking  things 
about  her  are  her  countenance  and  the  noises  she  makes. 
She  has  a  large  mouth,  and  as  her  visage  assumes  the  most 
doleful  aspect,  expressing  the  intensest  misery,  her  mouth 
begins  to  open  until  it  is  a  great  gaping  cavern,  and  she 
howls — "Oh,  John  dear!  doctor,  darlin' !  and  me  childer  ! 
and  me  persecuted  in  this  jail !  oh,  I'm  punished  !  dear  darhn' 
doctor  !  oh,  me  two  brothers  !  oh,  kilt  and  murdered  they  are  ! 
Oh!  oh!  oh!"     All  this  time  there  is  seldom  a  tear,  and  it 


84  STATES    OF   MEXTAL   DEPEESSION. 

goes  on  from  morning  till  night,  and  sometimes  all  niglit,  so 
that  you  cannot  hear  yourself  speak  within  10  yards  of  her. 
Though  the  misery  is  very  real  to  her,  yet  the  effect  is  often 
ludicrous,  as  if  you  were  looking  at  the  overdone  misery  of 
an  Irish  wake  on  the  stage.  She  ate  well,  and  her  bodily 
health  improved,  though  she  had  prolapsus  uteri,  for  which 
no  treatment  could  he  adopted.  After  twelve  years  she 
remains  insane,  hut  with  her  demonstrations  of  grief  subdued. 

Here  is  a  chronic  case  of  the  same  sort  that  lived  eleven 
years  : — 

A.  TV.,  aet.  45,  deaf  and  dumb,  but  educated.  A  "relative  " 
is  insane. 

For  seven  years  he  was  in  a  condition  which,  to  all  out- 
ward appearance,  was  that  of  misery  as  great  as  any  painter 
has  ever  depicted  as  the  lot  of  the  damned  in  hell.  He  was 
never  at  rest,  but  paced  about  "ndth  an  uneasy  nervous  gait. 
EQs  hands  were  always  moving,  tearing  liis  clothes  or  un- 
buttoning them,  or  masturbating,  which  he  did  in  the  most 
shameless  open  way ;  indeed,  he  was  doing  it  half  the  time. 
He  made  a  hideous  noise  nearly  all  the  time  between  a  groan 
and  a  hiss,  and  his  expression  of  face  was  that  of  absolute 
misery  and  fierce  desperation.  At  times  he  rushed  about, 
and  if  any  one  came  in  his  way  he  knocked  him  down ;  in 
fact,  he  had  a  distinct  homicidal  impulse,  which  made  him 
attack  those  near  him.  At  times  he  tore  his  flesh  and  beat 
his  head.  He  seemed  to  feel  no  pain.  He  was  the  worst 
patient  in  Morningside  Asylum,  and,  in  fact,  was  about  the 
worst  I  have  ever  seen,  taking  the  long  time  he  had  been 
affected  into  account.  Everything  had  been  tried  in  vain  for 
liis  recovery  and  amelioration.  Kothing  would  interest  him  ; 
scarcely  anything  would  quiet  him.  I  tried  hyoscyamine, 
and  it  nearly  poisoned  him.  I  gave  him  bromide  of  potassium 
in  doses  up  to  6  drachms  a  day.  I  tried  cannabis  indica  with 
it,  and  he  merely  fell  oif  in  flesh,  without  being  benefited. 
He  was  walked  in  the  fresh  air  till  two  strong  attendants 
were  done  up.     He  was  tried  to  wheel  heavy  barrows  of  soil. 


STATES   OF   MENTAL   DEPRESSION.  85 

but  the  figlit  to  get  him  to  do  so  threatened  to  run  some  risk 
of  killing  liim.  I  often  wished  I  could  castrate  him,  for  the 
constant  masturbation,  or  attempt  to  masturbate,  seemed  to 
show  that  the  centres  of  generation  were  in  a  state  of  morbid 
excitation,  and  I  think  it  might  have  done  him  good.  For 
the  last  three  years  of  his  life  he  was  more  quiet  and  de- 
mented, and  he  died  of  exhaustion,  with  some  tubercular 
disease  in  his  lungs. 

Tliis  is  another  cliwnic  case  of  motor  melancliolia,  of  a  hind 
which  is  very  common  in  old  age  : — 

A.  X.,  set.  77.  Single ;  gentlewoman.  Disposition  active, 
but  passionate.  First  attack.  No  exciting  cause  known.  Had 
a  fall  down  stairs  six  months  ago.  Became  very  restless  and 
sleepless,  and  lost  appetite.  This  condition  had  lasted  for 
three  months. 

On  admission  she  was  very  depressed  and  unsettled.  Could 
not  sit  down  or  rest  for  a  moment.  "Walked  about  the  room 
the  picture  of  despair,  and  took  no  interest  in  anytliing.  Was 
enfeebled  in  mind,  and  behaved  in  a  silly,  miserable  way. 
Her  physical  condition  and  general  health  were  poor,  and 
she  was  very  anxious  about  her  state  of  health  and  her  soul's 
salvation.  She  had  no  sleep  the  night  after  admission,  and 
was  very  noisy  and  restless.  She  was  very  depressed ;  begged 
to  be  sent  home ;  wrung  her  hands  and  wept.  This  continued 
with  little  change.  Her  nights,  with  few  exceptions,  were 
sleepless,  unless  narcotics  were  given ;  and  she  was  also  very 
noisy,  beating  at  her  bedroom  door  and  shouting  loudly. 
During  the  day  she  was  in  a  constant  state  of  miserable 
unrest.  She  was  suspicious  and  despondent ;  wished  she 
were  dead ;  refused  her  food ;  would  not  settle  to  any  work. 
This  state  of  unhappy  restlessness  and  excitement  became 
fixed  and  chronic,  while  her  mind  became  more  enfeebled. 
She  got  plenty  of  food,  but  never  could  be  fattened.  After 
three  years  she  began  to  show  distinct  signs  of  partial  hemi- 
plegia, which  was  first  on  one  side  and  then  on  the  other, 
each  attack  passing  off  in  a  few  days.     Two  of  the  former 


86  STATES   OF   MENTAL   DEPRESSION. 

assistant  physicians  to  tlie  Asylum,  Drs  Hayes  Il^ewington 
and  J.  J.  Brown,  liave  described  this  condition  and  its 
pathology,  attributing  it  to  capillary  apoplexies  occurring 
in  succession.'^  But  she  could  never  sit  down  for  any 
length  of  time  till  near  the  very  end,  a  year  after  the 
commencement  of  the  paralysis,  when  she  went  to  bed 
and  soon  died.  She  would  eat  her  meals  standing  and 
moving.  She  swore  and  used  blasphemous  language  to  her- 
self. She  said  she  would  "  burst "  if  she  was  made  to  sit 
down.  The  convolutional  motor  excitement  was  unceasing, 
and  nothing  could  exhaust  it.  It  was  connected  with  an 
irritation  in  the  process  of  the  decay  and  degeneration  and 
atrophy  of  the  brain  in  old  age — a  long-continued  brain-storm 
that  ended  only  with  life.  Such  old  people  are  most  difficult 
to  treat.  If  we,  by  mechanical  means,  restrain  their  move- 
ments, my  experience  has  been  that  it  is  no  real  conservation 
of  energy,  but  the  excitement,  finding  no  motor  outlet,  reacts 
inwards  and  makes  the  mental  state  much  worse. 

When  insanity  in  boys  and  girls  takes  the  melancholic  form, 
it  is  usually  attended  by  much  motor  excitation,  especially 
tceeping — the  boyish  mode  of  expressing  grief.  This  is  an 
example : — 

A.  Y.,  set.  12.  Disposition  excitable ;  habits  "  old- 
fashioned,"  sedentary,  thoughtful,  and  studious  for  liis  age. 
Several  brothers  and  sisters  died  in  infancy  of  head  aifections, 
and  a  paternal  uncle  had  been  melancholic.  Mother  nervous 
and  eccentric.  Father  died  of  consumption.  Had  been 
brought  \ip  in  a  poor  way  alone  with  an  old  grandfather, 
Hving  on  tea  and  coffee  and  no  milk.  Had  not  romped  and 
played  enough.  Had  been  in  the  habit  of  wetting  the  bed. 
His  father  died  a  few  months  ago.  Seemed  to  feel  it  keenly 
as  a  grown-up  man  would,  and  has  never  been  the  same  since. 
Of  late  has  dreamed  much,  and  awoke  in  the  middle  of  the 
night.     Has  been  at  school,  and  did  well.     Last  week  the 

^  Edin.  Med.  Jour.,  August  1874,  aud  Jour,  of  Mental  Scieiice,  July 
1877. 


STATES   OF  MENTAL  DEPEESSION.  87 

schoolmaster  cliecked  him  for  holding  his  pen  the  wrong  way. 
He  came  home  agitated,  nervous,  depressed,  and  confused. 
Talked  all  night  in  an  incoherent  way  of  holding  the  pen,  &c. 
He  has  got  worse,  till  he  is  now  much  depressed ;  crying, 
sometimes  with  tears,  sometimes  without,  all  the  time ; — by 
the  way,  melancholies  are  not  always  tearless ;  I  have  one  now 
who  literally  weeps  floods  of  tears.  He  was  very  restless  and 
sleepless ;  appetite  gone ;  was  flabby,  with  great  dilated  pupils, 
a  temperature  of  98°,  and  a  pulse  of  106,  and  weak.  Under 
Tine.  Belladonse  gtt.  x.  and  Potas.  Bromid.  gr.  xv.  twice  a 
day,  fresh  air,  milk,  and  light  work,  he  rapidly  improved, 
and  was  well  in  a  fortnight.  He  wets  the  bed  much  less,  too, 
when  well.  But  in  four  months,  when  employed  as  a 
message  boy,  he  began  to  fancy  he  was  dishonest ;  got  con- 
fused, wept  loudly,  was  depressed  and  nervous,  and  dreamed 
terrible  dreams.  He  got  well  again,  and  then  relapsed.  His 
tendency  to  recurrence  and  relapse  is  characteristic  of  all  the 
mental  diseases  and  of  nearly  all  the  neuroses  of  childhood, 
puberty,  and  adolescence.  During  his  first  attack  he  cried, 
screamed,  moaned,  groaned,  and  was  restless,  more  markedly 
than  during  liis  subsequent  attacks.  In  two  years  from  the 
first  attack,  after  many  relapses,  he  was  sent  to  the  Asylum, 
and  there,  under  proper  diet  and  treatment,  he  got  fat  and 
cheerful,  making  a  permanent  recovery. 

One  gets  a  good  idea  of  excited  motor  melancholia  from  a 
case  of  delirium  tremens,  which,  looked  at  from  a  symptomato- 
logical  point  of  view,  is  a  typical  example  of  this  disease. 

Trophic  affections  such  as  boils,  skin  itchiness,  and  irrita- 
tions, causing  the  patients  to  pick  their  skin,  tear  out  their 
hair,  and  bite  their  nails  down  to  the  quick,  are  particularly 
apt  to  occur  in  the  marked  forms  of  this  excited  melancholia, 
showing  that  the  disturbances  are  profound,  and  extend 
specially  to  the  trophic  functions  of  the  brain.  For  the  same 
reason,  no  doubt,  some  of  the  cases  are  intractably  prolonged, 
and  many  are  incurable.  In  no  variety  of  the  disease  do  the 
muscular  attitudes  and  expressions  of  mental  pain  get  so  fixed. 


88  STATES   OF  MENTAL  DEPEESSION. 

I  had  lately  a  case  who  has  been  melanchohc  for  over  twenty 
years,  whose  power  of  really  feeling  mental  pain  has  gone,  but 
who  wrings  her  hands  and  groans,  whose  attitude  is  bent  and 
despairing,  and  whose  face  in  deep  furrows  expresses  the 
intensest  melancholy.  This  state  will  come  on  quite  suddenly, 
without  any  outward  cause.  If  interrupted  in  the  middle  of 
one  of  these  attacks  of  agitated  psychalgia,  and  asked — 
"What's  the  matter,  IVIiss  Z.  ?  what  are  you  crying  about?" 
she  will  smile  and  say — "I  don't  know."  "Were  you 
unhappy  1 "  "  No."  Or  if  a  glass  of  wine  or  a  bit  of  cake  is 
presented  during  the  midst  of  the  worst  paroxysm,  she  will 
stop  her  groaning,  take  it,  and  smile.  And,  by  assuming  a 
sorrowful  or  a  jovial  tone  of  voice,  one  can  make  her  groan  or 
smile,  and  even  sing  a  song.  The  melanchoHa  has  in  time 
become  muscular  and  automatic,  without  any  real  subjective 
feehng  at  all,  and  there  is  no  memory  of  pain  or  pleasure. 
This  interesting  psychological  condition  is  only  seen  when  the 
convolutions  are  wasted  or  destroyed  structurally.  This  con- 
dition is  often  seen  in  old  persons.  The  brain  is  more  pro- 
foundly disturbed  in  its  functions  in  the  excited  than  in  any 
other  form  of  melanchoha  except  that  with  epileptiform 
convolutions. 

Treatment. — Regarding  the  treatment  of  excited  melan- 
choha, it  might  at  first  sight  appear  that  mechanical  restraint 
of  the  movements  of  such  cases,  or  at  all  events  narcotic  and 
temporarily  paralysing  drugs,  would  be  indicated,  to  conserve 
the  energy  and  to  save  exhaustion.  In  former  times  tliis  plan 
of  treatment  was  acted  on  habitually.  In  exceptional  cases  we 
do  so  still,  but  a  closer  study  of  the  affection  and  the  results 
of  experience  show  us  that  evil  results  of  the  gravest  kind 
are  apt  to  arise  by  the  indiscriminate  restraining  of  motion 
either  mechanically  or  chemically.  We  see  that  the  motor 
effects  are  the  natural  outcome  and  outlet  of  morbid  energy 
generated  in  the  brain  ideo-motor  centres.  If  they  are 
restrained,  the  condition  of  the  brain  seems  to  suffer,  tlie 
excitement  to  increase,  and  there  is  much  greater  risk  of  its 


STATES   OF   MENTAL  DEPEESSION.  89 

exhausting  and  killing  the  patient,  or  of  the  brain  condition 
becoming  incurable.  So  we  let  the  patients  walk,  shout,  even 
at  the  risk  of  tumbling  and  accident,  and  we  try  and  send  the 
motor  energy  into  normal  directions  by  much  hard  walking  in 
the  open  air,  free  scope,  garden  work,  wheehng  barrows,  &c. 

I  take  the  following  case  as  a  good  example  of  the  effects  of 
such  rational  treatment  in  motor  melancholia  in  what  ivas  a  very 
severe  example,  and  of  the  possibility  of  treating  such  a  case  to 
a  favourable  termination  out  of  an  asylum,  during  the  whole  of 
its  course,  when  circumstances  are  favourable  : — 

B.  A.,  set.  60,  a  retired  professional  man,  who  had  been  in 
many  climates.  Temperament  was  sanguine,  diathesis  nervous, 
disposition  very  lively  and  social ;  habits  active.  He  once 
before  had  a  short  attack  of  depression,  and  had  recovered  at 
home.  The  present  attack  began  by  simple  depression  and 
falhng  off  in  weight.  He  then  passed  through  a  hypochondri- 
acal stage,  complaining  constantly  of  his  bowels  and  digestion 
and  liver.  Those  ideas  increased  until  he  had  fixed  visceral 
delusions.  He  had,  as  a  matter  of  fact,  prolapsus  ani,  but  in 
imagination  his  bowels  were  all  diseased,  and  his  powers  of 
swallowing  gone.  His  next  stage  was  that  of  active  motor 
excitement,  showing  constant  restlessness  by  night  and  day, 
shouting,  tearing  out  his  hair,  and  picking  his  skin  into  holes. 
He  recovered  rather  suddenly  in  about  a  year  from  the  be- 
ginning of  his  illness,  after  he  had  gained  about  28  lbs.  in 
weight.  His  treatment  was  throughout  tonic  and  nutrient — 
quinine,  the  mineral  acids,  arsenic,  iron,  the  bitter  natural 
waters,  and  strychnine.  He  took  as  much  as  eleven  tumblers 
of  milk, a  day,  and  the  only  thing  that  at  one  period  of  his  case 
made  us  not  give  up  hope  was  that  he  was  able  to  digest  this, 
and  that  he  gained  weight,  except  during  the  most  excited 
stage,  which  lasted  for  four  months.  He  took  Tr.  cannabis 
indicse  and  bromide  of  potassium  for  the  excitement  with 
marked  benefit,  and  I  once,  when  he  was  very  excited  but 
improving  in  strength,  had  his  occiput  shaved  and  a  large 
blister  applied,  also  with  benefit.     He  took  no  animal  food 


90  STATES    OF   MENTAL   DEPEESSION. 

during  his  illness.  Warm  baths,  with  cold  to  his  head,  pro- 
duced temporary  quietude  during  his  excitement.  He  had  a 
first-rate  male  attendant  and  a  devoted  wife,  and  lodged  in  a 
suhurban  villa  with  a  large  garden,  where  he  stayed  nearly  all 
day,  driving  and  walking  out  when  quiet.  I  have  never  treated 
a  worse  case  of  melancholia  out  of  an  asylum. 

Resistive  {Obstinate)  Melanclwlia. — In  many  cases  of  melan- 
cholia, obstinacy,  an  unreasoning,  passive,  or  active  resistance 
to  anytliing  that  other  people  want  them  to  do,  is  the  marked 
feature  of  this  disease  :  to  dressing,  to  undressing,  to  taking 
food,  to  going  to  bed,  to  getting  up,  to  going  out,  to  moving 
about,  to  micturating,  &c.  "When  this  resistance  is  very 
extreme,  as  it  sometimes  is,  it  is  a  trying  and  very  dangerous 
complication,  from  the  difficulty  of  overcoming  it  and  carrying 
out  necessary  treatment  withoiit  hurting  the  patient.  I  have 
often  had  nurses  and  officers  come  and  report  to  me — "  "We 
will  not  go  on  dressing  except  a  doctor  is  present.  There  is 
great  risk  of  breaking  his  bones  or  injuring  him."  It  is 
evident,  too,  that  overcoming  the  resistance,  and  making  the 
patient  do  things  contrary  to  his  will,  is  often  attended  with 
aggravation  of  his  mental  pain,  causing  excitement,  and  even 
violence.  As  a  general  rule  he  cannot  say  why  he  resists, 
but  he  does  so  persistently,  doggedly,  unreasonably,  and  in 
some  cases  with  fierce  violence.  It  is  one  of  the  symptoms 
that  try  most  the  patience  of  attendants  and  nurses,  especially 
of  the  less  gentle  and  reasonable  sort.  They  cannot  under- 
stand that  it  is  a  mere  symptom  of  disease,  and  are  apt  to 
treat  it  as  if  it  were  sane  obstinacy.  Resistance  is  sometimes 
combined  with  active  motor  agitation,  but  most  frequently  it 
is  passive  obstinacy.  It  is  often  one  direct  result  of  the 
delusions  present.  One  patient  fancies  he  cannot  pay  for  his 
clothes  or  food,  and  so  wiU  not  wear  the  one  nor  eat  the  other ; 
another  fancies  that  she  is  taken  to  execution,  and  so  will 
not  walk ;  another  is  to  be  made  a  spectacle  of,  and  so  will 
not  associate  with  other  patients.  Some  have  vague  feehngs 
of  distress  that  the  house  is  falling  and  that  the  ground  is 


STATES   OF   MENTAL  DEPRESSION.  91 

unsteady,  and  so  will  not  move.  One  very  resistive  ivoman 
I  have  now  as  a  patient — B.  B. — who  will  not  do  anything 
that  is  good  for  her.  She  will  not  put  on  her  clothes  or 
shoes,  and  says,  in  a  vague,  incoherent,  fearful  way — "  It's 
awful,  I'm  trampling  myself  down  under  the  ground  (and  so 
she  will  not  walk).  I'm  in  a  hole  to  serve  other  people. 
I've  neither  meat  nor  drink  (she  had  both  before  her,  but  in 
regard  to  those  she  had  not  the  sweet  sense  of  possession). 
I  dinna  ken  the  beginning  o't,  and  I  dinna  ken  the  end  o't. 
I  never  thocht  I  was  to  be  the  key  o'  the  earth.  Every- 
thing's naething.  I've  come  miles  and  miles.  It's  awfu'. 
I  was  forty  when  they  changed  me  into  this  state.  I  dinna 
ken  what  age  I  am  now.  They've  greased  me  a',  and  gin' 
me  oil  (castor  oil),  and  done  a'  kinds  o'  things,  and  there's 
no  a  bit  o'  wit  in  me."  She  shows  that  there  is  some 
delusional  doubt  in  her  mind  as  to  her  own  personal  identity, 
as  to  the  ground  on  which  she  stands,  as  to  time  and  space, 
and  as  to  her  own  age  ;  and  she  puts  a  bad  construction  on 
every  act  done  by  others,  accusing  them  of  all  her  ills.  Her 
sensibility  and  muscular  sense  are  perverted.  Extreme 
obstinacy  in  cases  of  melancholia  is  usually,  in  my  ex- 
perience, the  result  of  a  complicated  and  deep  delusional 
state  such  as  this,  or  to  an  insane  stupidity,  confusion  of 
mind,  want  of  power  of  comprehension  or  attention.  There 
is  an  element  of  stupor  in  many  of  them — delusional  stupor. 
One  may  not  at  the  time  be  able  to  make  out  what  the 
delusions  are,  but  patients  can,  after  recovery,  usually  tell 
what  they  were.  In  some  of  these  cases  I  am  reminded  of 
the  resistance  of  a  wild  animal  when  first  caught.  Fear,  the 
instinct  of  self-preservation,  unreason,  suspicion,  and  the 
instinct  of  freedom,  are  all  mixed  up  in  the  case.  An 
evolutionist  would  have  no  difficulty  in  seeing  in  those 
phenomena  a  reversion  to  primitive  instincts,  I  have  often 
seen,  as  clinical  accompaniments  of  such  cases,  a  hot-feeling 
perspiring  skin  and  a  particularly  oflfensive  strongly  smelling 
perspiration.     Women  have  often  greater  mental  confusion 


92  STATES   OF   MENTAL  DEPEESSION. 

and  obstinacy  at  the  menstrual  periods.  Masturbation  in 
both  sexes  often  causes,  aggravates,  and  accompanies  this 
condition.  They  often  admit  afterwards  that  it  was  this 
habit  which  aggravated  their  confusion  and  obstinacy  during 
the  ilhiess,  but  say  that  it  was  almost  involuntary  and 
automatic  at  the  time.  I  have  now  a  lady — B.  C. — under 
my  care,  whose  obstinacy  is  so  extreme  that  it  sometimes 
takes  six  attendants  to  dress  her,  yet,  when  the  first  article 
of  clothing  is  put  on,  she  will  sometimes  finish  her  dressing 
herself.  A  locked  door  makes  her  furious  to  open  it,  so  we 
allow  her  to  go  where  she  likes,  and  almost  do  what  she 
likes.  She  will  stand  in  a  passage  for  hours,  evidently  un- 
certain what  to  do,  but  any  attempt  to  make  her  go  one  way 
will  certainly  tend  her  to  go  the  other  with  all  her  might. 
When  opposed  she  is  fiercely  resistant,  attacking  those  about 
her  violently  at  times.  Eesistance  to  taking  food  in  such 
cases  is  common  and  very  prejudicial  to  their  recovery.  They 
are  unpersuadable,  but  sometimes  when  the  first  mouthful  is 
forced  into  their  mouths  they  will  then  finish  the  meal.  In 
other  cases,  if  food  is  left  near  them  in  an  out-of-the-way 
place,  they  will  go  and  eat  it  by  stealth,  denying  the  fact 
afterwards.  We  often  take  advantage  of  this  pecuharity  to 
get  them  to  take  food.  In  some  of  those  things  they  are 
exactly  like  a  wild  animal  beginning  to  be  tamed. 

Tliis  condition  sometimes  has  more  of  confusion  and 
stupidity  than  resistance  or  obstinacy,  and  when  that  is  so 
it  is  alhed  to  melanchohc  stupor,  of  which  I  shall  speak  in 
another  lecture.  In  fact,  I  have  seen  resistive  melanchoha 
as  a  stage  in  a  case  passing  into  stupor,  and  then  again  a 
further  stage  in  passing  out  of  it  towards  recovery. 

The  folloiving  loas  a  prolonged  case  of  resistive  melancholia 
who  recovered  : — B.  D.,  set.  40.  Married.  Temperament 
bihous ;  diathesis  nervous ;  disposition  cheerful ;  habits 
active.  K"o  children.  First  attack  :  duration  eleven  months. 
Assigned  cause,  depression  from  diarrhoea.  Slight  symptoms 
at  first  suggesting  epilepsy,  but   no  true  convulsion.      Her 


STATES   OF   MENTAL   DEPRESSION.  93 

father  was  epileptic,  and  a  sister  insane.  She  became  de- 
pressed, and  refused  food,  requiring  the  use  of  the  stomach 
tube  for  two  months.  Had  delusions,  e.g.,  that  her  husband 
was  near  her  when  he  was  far  away.  At  first  she  was 
treated  in  a  private  house,  but  her  extreme  obstinacy  about 
eating,  dressing,  undressing,  walking  out,  and  coming  home 
when  out,  implied  more  attendance  at  times  than  could  be 
got  in  any  private  house. 

On  admission  to  Morningside  Asylum  she  was  found  to  be 
labouring  under  melancholia,  and  to  be  in  fair  bodily  health. 
Two  months  after  admission  it  is  noted  : — "  B.  D.  continues 
very  restless,  suspicious,  and  obstinate,  and  it  is  with,  difficulty 
she  can  be  got  to  do  anything.  She  occasionally  plays  on 
the  piano,  but  only  does  so  to  get  a  newspaper,  which  she 
seldom  reads,  but  carries  about  with  her  and  will  not  give 
up  again,  beheving  it  contains  messages  from  a  friend. 
There  is  no  active  excitement  or  any  other  symptom,  simply 
passive  resistance  to  almost  everything.  She  constantly 
imagines  that  some  relative  of  hers  has  come  to  see  her ; 
and,  when  out  walking,  will  look  into  all  sorts  of  imjDrobable 
places  for  this  person.  She  sleeps  fairly  at  nights,  but 
awakes  very  early  in  the  morning,  and  is  then  very  restless. 
Takes  her  food  well ;  gets  tonics  of  all  sorts."  Continued, 
after  eighteen  months,  as  restless  and  obstinate  as  ever, 
and  could  not  be  got,  without  much  trouble,  to  do  any  work. 
Slept  badly,  and  was  often  restless  at  night.  Took  plenty 
of  food,  and  kept  in  fair  bodily  health.  She  was  addicted 
to  masturbation,  and  after  recovery  believed  that  caused  her 
bad  symptoms.  Looked  sometimes  very  demented,  and 
could  not  be  got  to  do  much  work.  Slept  rather  better. 
Prognosis  seemed  very  doubtful.  During  the  latter  half  of 
the  second  year  she  was  able  to  go  out  into  town  on  several 
occasions ;  and  in  the  end  of  it  she  was  more  settled  and 
tidy  in  her  ways,  but  still  full  of  the  delusions  about  people 
being  present  who  were  not,  &c. 

In  three  years,  after  various  trips  to  the  seaside,  and  a  tour 


94  STATES   OF  MENTAL   DEPKESSION. 

in  the  Higlilands,  she  had  improved  sufficiently  to  leave  the 
asylum  on  a  year's  probation,  going  first  to  hve  in  a  family  for 
a  year,  then  taking  a  tour  on  the  Continent,  and,  finally,  heing 
able  to  take  up  housekeeping  for  herself,  getting  rid  of  her 
mental  disease,  becoming  very  stout,  healthy,  and  cheerful 
after  about  five  years  from  the  commencement  of  her  attack, 
and  continuing  so  for  now  twenty  years.  This  case  shows 
that  treatment  should  he  continued,  and  hope  should  not  ie 
given  up  for  a  long  time  in  this  disease. 

The  folloiving  is  prohably  an  incurahle  case  : — B.  E.,  ast.  46. 
Single.  Education  good  ;  disposition  cheerful ;  habits  active 
and  industrious.  Xo  known  hereditary  predisposition  to 
insanity.  First  attack  :  duration  two  months ;  predisposing 
cause,  change  of  life.  She  became  depressed  and  had  melan- 
chohc  delusions,  e.g.,  that  she  had  committed  some  crime,  and 
must  be  punished ;  complained  of  headache,  neuralgia,  and 
uterine  disorder. 

On  admission  she  had  a  look  of  stoKd  misery,  was  evidently 
much  depressed  in  spirits,  was  very  obstinate  and  intractable, 
refused  her  food,  was  very  taciturn,  and  showed  a  good  deal 
of  motor  excitement.  Her  physical  condition  was  poor,  but 
there  were  no  evidences  of  organic  disease. 

From  the  beginning  there  was  the  greatest  difficulty  in 
nourishing  her,  and  for  nearly  ten  months  the  nose  tube  had 
to  be  used  regularly.  She  resisted  the  operation  of  feeding  in 
the  most  obstinate  and  dogged  manner,  the  services  of  some 
half  dozen  attendants  being  usually  required  before  a  meal 
could  be  given.  In  the  same  manner  she  resisted  being 
dressed,  undressed,  taken  out  for  exercise,  going  to  the  water- 
closet,  or  leaving  it  when  there.  Her  resistance  was  not 
passive,  but  very  active  indeed ;  she  would  often  strike  and 
kick  those  who  wished  to  make  her  go  out,  and  she  would 
seize  hold  of  anytliing  near,  and  nothing  but  force  would 
overcome  her  resistance. 

Her  condition  improved  considerably  for  a  few  months,  and 
the  nose  tube  was  dispensed  -nith.     She  gained  in  weight,  did 


STATES   OF   MENTAL  DEPEESSION.  95 

a  little  useful  work,  and  at  times  talked  rationally  and  cheer- 
fully. This  improvement,  however,  did  not  persist.  The 
prognosis  is  bad  now  after  ten  years.  Dirty  habits  developed 
eighteen  months  after  the  commencement  of  the  attack.  A 
hsematoma  which  appeared  is  in  such  a  case  almost  sufficient 
to  warrant  a  verdict  of  incurability. 

Melancholia  luith  Ej^ileptiform  Attacks  {Convulsive  Melan- 
cholia).— In  the  excited  form  of  melancholia  the  motor  move- 
ments are  ideo-motor  and  volitional — that  is,  co-ordinated 
motions  and  indications  of  emotional  depression  without 
necessary  loss  of  consciousness  and  memory.  But  in  the  form 
I  am  now  to  describe,  which  is  very  rare  indeed,  and  has  not 
been  before  described,  the  motor  affection  is  a  true  convulsion 
with  unconsciousness,  occurring  once  or  twice,  seldom  oftener, 
in  the  course  of  the  attack  ;  and  it  differs  in  no  way  in  some 
cases  from  an  ordinary  epileptic  fit,  and  in  others  in  no  way 
from  a  general  paralytic  epileptiform  attack.  This  form  of 
melanchoha  is  in  my  opinion  one  of  the  most  serious  varieties 
of  the  disease.  In  it  the  whole  of  the  functions  of  a  brain 
convolution  are  affected — mental,  motor,  sensory,  trophic,  and 
vaso-motor.  The  mental  depression  is  very  intense,  accom- 
panied by  muscular  agitation  and  excitement,  and  usually  by 
great  obstinacy.  There  is  usually  much  insensibility  to  pain, 
and  a  tendency  to  skin  irritations,  so  that  the  patients  scratch 
themselves  and  pick  holes  in  their  skin,  or  rub  off  their  hair 
or  pull  it  out  in  patches.  They  are  aU  prolonged  and  prac- 
tically incurable,  for  I  have  seen  only  two  make  even  modified 
recoveries,  and  none  of  them  have  ever  been  able  to  work 
afterwards.  It  must  be  understood  that  I  do  not  include  in 
this  variety  convulsions  of  syphilitic  or  alcoholic  origin.  Con- 
vulsions are  present  in  certain  cases  of  those  two  kinds  of 
insanity,  but  I  shall  refer  to  them  under  those  headings. 
This  variety  of  melancholia  seems  to  have  a  distinct  pathology. 
I  have  never  met  with  any  case  but  one  where,  after  death, 
some  cause  of  irritation  or  some  limited  adhesion  of  the  pia 
mater  to  the  convolutions  was  not  found,  just  as  in  general 


96  STATES   OF   MENTAL   DEPKESSION. 

paralysis,  not  at  the  vertex,  but  on  some  of  the  basal  con- 
volutions. The  structure  of  the  convolutions  is  altered  on 
microscopic  examination,  there  being  proliferation  of  the 
nuclei  of  the  neurogha,  especially  seen  round  the  arterioles 
and  capillaries,  with  destruction  of  many  of  the  nerve  cells. 

I  have  seen  over  a  dozen  of  these  cases,  but  of  eight 
I  have  records  since  I  reahsed  that  this  was  a  distinct 
pathological  variety  of  melanchoHa — almost  the  only  variety 
that  can  be  correctly  so  described.  Of  those  eight  cases  five 
had  only  one  epileptiform  attack,  two  had  two,  and  one  had 
many.  In  six  they  happened  witliin  three  months  of  the 
beginning  of  the  disease,  in  one  after  three  years,  and  in  one 
only  after  twenty  years.  In  three  of  them  the  patients  died 
within  three  years  ;  in  five  they  lived — one  for  twenty-four, 
one  for  ten,  one  for  nine,  and  one  for  eight  years.  They 
differ  entirely  from  ordinary  epileptics,  and  from  the  cases 
with  occasional  epileptic  fits  that  sometimes  occur  in  advanced 
dementia,  as  the  brain  gets  wasted ;  and  they  are  certamly 
not  cases  of  general  paralysis,  for  the  speech  is  not  affected. 

The  following  are  examples  of  convulsive  melancholia  : — 

B.  F.,  aet.  61.  Single.  Temperament  melancholic.  Educa- 
tion good ;  disposition  cheerful,  with  periods  of  irritabihty  ; 
habits  perfectly  steady  ;  teetotaller.  One  previous  attack  of 
melanchoHa.  Hereditary  predisposition  to  insanity  ;  exciting 
cause  unknown.  The  attack  began  by  a  running  down  of 
bodily  health  generally.  Duration  of  existing  attack  three 
or  four  months.  Has  been  depressed,  and  lately  has  had 
two  epileptiform  seizures,  each  lasting  about  five  minutes. 
Attempted  to  cut  his  throat  the  day  before  admission. 

On  admission  was  very  depressed,  and  had  many  melancholy 
delusions.  Said  that  he  had  lost  all  his  money  and  was 
entirely  ruined,  that  he  was  hundreds  of  pounds  in  debt,  and 
that  he  can  never  pay  what  he  owes.  He  was  taciturn, 
obstinate,  and  reticent,  and  displayed  a  confused  impairment 
of  memory.  He  was  in  feeble  health,  and  had  slight  kidney 
and  Hver  disorder. 


STATES  OF  MENTAL  DEPRESSION.  97 

The  prominent  feature  in  this  case  came  to  be  a  curious, 
unreasoning,  automatic  obstinacy.  When  dinner  is  announced, 
for  example,  no  persuasion  will  get  him  to  go  down  to  the 
dining-room ;  and  when  requested  to  go  out  to  walk  he  simply 
will  not  go.  He  can  give  no  reason  for  his  refusal,  and  when 
force  is  used  he  resists  with  all  his  strength.  In  other  respects 
he  behaves  in  a  very  quiet  and  sedate  manner.  He  is  a  very 
diligent  reader,  wakening  up  to  activity  when  fresh  news- 
papers or  periodicals  are  brought  in.  He  is  usually  little 
given  to  conversation,  and  he  is  slow  to  reply  to  any  observa- 
tion made  to  him.  He  is  still  very  despondent,  believing  that 
he  is  ruined,  and  that  he  has  not  a  penny  of  his  own,  but  he 
has  occasional  outbursts  of  fun,  and  even  plays  httle  practical 
jokes  at  times,  and  laughs  at  the  result.  Now  and  then  he 
will  talk  as  animatedly  and  intelligently  about  things  as  ever 
he  did  in  his  hfe,  and  one  could  not  then  say  there  was  any- 
thing wrong  with  him.  Yet,  in  the  midst  of  this,  if  his 
dinner  is  anfiounced,  or  the  time  comes  to  go  out  to  walk,  he 
will  become  confused  and  obstinate,  and  will  need  to  be  taken 
out  of  the  room  by  force,  no  amount  or  kind  of  persuasion  at 
all  avaihng.  Has  had  no  more  epileptiform  seizures,  but  did 
not  improve  or  change  mentally.  After  eleven  years  of  this 
condition  he  died  of  bronchitis  at  72,  but  no  post-mortem 
examination  was  allowed. 

The  following  was  a  case  of  convulsive  melancholia  become 
chronic,  with  muscular  expr^essions  of  mental  pain,  but  no  real 
feeling.  Enfeehlement  of  mind ;  tivo  epileptiform  attacks — 
one  twenty  years  after  the  other. 

B.  H.,  set.  36,  when  admitted,  laboured  under  melancholia. 
Had  been  treated  in  the  Asylum  ten  years  before,  and  had 
recovered.  Insanity  supposed  to  be  due  to  too  free  use  of 
stimulants.  After  eight  years'  residence  she  was  discharged 
improved,  but  within  three  years  she  was  brought  back. 
She  was  greatly  excited  —  crying,  moaning,  wringing  her 
hands,  and  displaying  generally  a  picture  of  the  most  intense 
misery,  and  had  an  epileptiform  fit  soon  after  admission. 

G 


98  STATES  OF  MENTAL  DEPKESSION. 

She  has  now  been  for  twenty-one  years  in  a  condition  of 
melancholia ;  but  with  the  lapse  of  time  her  feelings  have 
become  so  blunted,  and  her  intellectual  faculties  so  dull, 
that  while  she  still  wears  all  the  trappings  and  the  suits 
of  woe,  her  face  drawn  and  furrowed,  and  in  a  fixed  state 
muscular ly  of  utter  misery,  her  attitude  that  of  utter  dejec- 
tion, and  constantly  wringing  her  hands  and  utteriag  a  sound 
between  a  wail  and  a  groan — she  is  inwardly,  if  not  happy, 
at  least  free  from  real  conscious  remembered  mental  pain. 
For  about  two  days  in  each  week  she  is  wonderfully  bright 
and  sensible.  At  other  times  she  is  very  stupid  and  helpless. 
At  her  best  she  is  much  enfeebled  in  mind,  and  is  childish 
and  forgetful.  She  rubs  the  hair  off  parts  of  her  head 
incessantly,  and  often  for  hours  she  calls  out — "  Oh  dear ! 
oh  dear ! "  in  the  most  doleful  tones.  But  when  asked  if 
she  is  unhappy,  she  smiles  and  says — "  Oh,  no ; "  and  she 
will  chat  away  in  a  pleasant,  garrulous  manner,  and  will 
sLng  a  snatch  of  a  song  or  play  a  tune  on  the  piano,  or  beg 
for  a  bit  of  cake.  She  had  her  second  general  epileptiform 
seizure  in  1880,  twenty-one  years  after  the  first.  She  died 
at  the  age  of  71,  and  several  bony  spicules  were  found  in 
her  dura  mater  projecting  into  the  motor  area  of  the  cortex. 
There  were  no  •  adhesions  of  the  pia  to  the  cortex,  and  no 
granulations  of  the  ventricles.  But  on  microscopic  examina- 
tion the  pia  was  found  thickened,  with  blood  between  its 
two  layers  in  some  places.  There  was  a  sclerosed  layer  on 
the  surface  of  the  cortex.  The  pericellular  spaces  were 
enormously  enlarged,  with  much  atrophy  of  the  cell  sub- 
stance in  all  the  layers  of  the  cortex,  and  there  was  much 
pigmentary  degeneration  of  the  large  cells  of  the  third 
layer. 

Organic  Melancholia  {the  Melancholia  accompanying  Gross 
Organic  Brain  Disease). — There  are  mental  symptoms,  often 
only  amounting  to  depression  of  spirits,  which  accompany 
coarse  organic  disease  of  the  brain,  tumours,  softenings,  and 
wastings.     It  is  usually  in  the  first  stages  of  those  diseases 


STATES  OF  MENTAL   DEPRESSION.  99 

that  we  have  the  mental  depression,  though  in  some  cases  it 
continues  till  death.  In  some  of  those  cases  I  have  seen 
the  mental  symptoms  the  very  first  to  appear,  long  before 
cephalalgia  or  paralysis,  or  even  before  great  bodily  weakness 
made  its  appearance.  A  paralysis  of  the  sense  of  well-being 
and  the  enjoyment  of  life,  a  difficulty  in  coming  to  decisions, 
a  loss  of  mental  energy,  an  intolerance  of  the  usual  work, 
if  not  an  actual  incapacity  to  do  it  well,  an  irritability  of 
temper,  a  tendency  to  make  slight  mistakes  in  small  things, 
a  loss  of  memory,  and  a  subacute  mental  pain,  I  have  seen 
to  exist  for  two  years  before  men  showed  any  diagnostic 
signs  of  brain  ramollissement  or  tumour.  The  melancholia 
is  usually  of  the  simple  type,  seldom  assuming  the  excited, 
delusional,  or  distinctly  suicidal  form.  I  have  seen  it  of 
the  hypochondriacal  kind  in  a  few  cases.  Organic  melan- 
cholia commonly  ends  in  organic  dementia  as  the  brain 
disease  progresses,  if  the  patient  lives  long  enough.  But  the 
patients  seldom  need  to  be  sent  to  lunatic  asylums  if  they  have 
money  enough  to  pay  for  home  nursing  and  attendance. 

The  following  is  a  typical  case  of  organic  melancholia, 
interesting  from  the  bodily  as  well  as  from  the  mental  point 
of  view  : — 

B.  J.,  set.  35.  Melancholic  temperament,  nervous  dia- 
thesis, cheerful  disposition,  and  very  industrious  habits.  An 
unusually  intelligent  man,  who  after  his  business  hours  (and 
they  were  long  and  hard)  read  books  on  philosophy  and 
science.  There  was  no  known  heredity  to  mental  or  brain 
disease.  He  had  mental  worry  and  business  disappointment, 
followed  by  a  weariness,  lassitude,  and  loss  of  energy.  The 
disease  began  by  his  being  forgetful  of  things.  This  he  was 
conscious  of,  and  it  worried  and  depressed  him,  and  from 
some  expressions  he  used  his  friends  feared  suicide.  He 
had  at  the  same  time  headaches,  then  he  smelt  bad  odours 
where  none  existed — a  grave  symptom  always  —  then  he 
began  to  take  short  unconscious  attacks,  without  convulsion 
or  falling  down,  sometimes  several  times  a  day. 


100  STATES   OF   MENTAL  DEPRESSION. 

"When  I  saw  liim  first,  eight  months  after  the  symptoms 
had  begun,  he  was  depressed,  but  without  any  intellectual 
delusion.  He  could  not  read  nor  apply  himself  to  anything ; 
his  memory  was  bad;  he  had  terrible  headaches,  and  a 
f eehng  of  a  band  round  his  head ;  his  head  was  not  pained 
by  tapping  with  the  finger ;  his  right  face,  arm,  hand,  and 
leg  were  weaker  than  the  left,  and  he  had  a  peciihar  slow 
mode  of  speech,  a  difficulty  in  remembering  words,  and  a 
tendency  to  use  wrong  words  having  the  same  general  sound 
to  those  he  wished  to  use.  Sexual  desire  and  capacity  had 
ceased  for  six  months.  He  was  constantly  sleepy  and 
yawning,  and  would  go  to  sleep  as  he  sat  and  talked  to 
one ;  in  fact,  all  the  time  he  seemed  hke  a  man  half  asleep 
— a  grave  symptom  too.  He  had  a  perpetual  weariness. 
Face  very  heavy  and  expressionless.  When  very  bad  one 
day,  and  he  wanted  to  say  he  never  had  a  foul  tongue,  he 
said — "I  never  was  Hke  some  folks  that  show  that  they 
have  a  strong  colour  on  the  tone — on  the  tongue."  His 
bowels  were  excessively  costive.  My  diagnosis  was  serious 
brain  disease  affecting  the  convolutions,  but  chiefly  confined 
to  the  left  side.  I  thought  it  was  either  softening  or  tumour. 
In  case  it  might  be  of  syphihtic  origin,  and  also  because  I 
had  found  this  treatment  gave  rehef  in  cases  of  this  kind 
of  non-specific  origin,  I  put  him  on  large  doses  of  the 
bromide  and  iodide  of  potassium,  mth  jV-grain  doses  of 
corrosive  sublimate.  I  also  blistered  his  head  severely  behind. 
This  treatment  undoubtedly  reheved  the  intensity  of  the 
pain,  and  stopped  the  epileptiform  attacks.  His  temperature 
was  at  this  stage  subnormal,  seldom  exceeding  97°.  In  three 
weeks  after  I  saw  him  he  had  got  distinctly  worse.  He 
walked  worse,  staggered,  and  would  fall  backwards  and  to 
the  right  if  left  alone.  He  spoke  worse,  and  wrote  worse, 
e.g.,  when  I  asked  him  to  write  "my  hat,"  which  was  before 
him,  he  wrote  slowly  "  mhate."  His  temperature  was  100° 
one  evening.     He  died  suddenly  next  morning. 

On  post-moHem   examination,   I   found   on   removing   the 


STATES   OF   MENTAL   DEPRESSION.  101 

dura  mater  that  the  convolutions  bulged,  and  were  flattened, 
especially  on  left  side.  The  whole  of  the  middle  lobe  of  the 
left  side  felt  baggy  and  fluid  on  pressure.  On  section  the 
lateral  ventricle  of  that  side  was  enlarged,  and  almost  all 
the  white  substance  of  that  lobe  was  gelatinous,  stringy, 
with  a  pale  straw-coloured  fluid  oozing  from  it.  It  was,  in 
some  respects,  unlike  any  case  of  brain  softening  I  had  ever 
seen.  The  grey  matter  forming  the  gyri  of  the  middle  lobe 
was  pale  and  soft,  but  not  diffluent  or  gelatinous.  The  pia 
mater  stripped  off  it  very  readily.  The  corpus  striatum  and 
optic  thalamus  of  that  side  were  softened  to  some  extent. 
I  could  find  no  embolism  nor  thrombosis  of  any  of  the  arteries 
to  account  for  the  softening.  The  anterior  and  posterior 
lobes  were  pale  and  wanting  in  consistence,  but  not  gelatinous. 
Broca's  convolution  was  not  greatly  affected.  The  right 
liemisphere  was  pale  and  soft,  especially  the  whole  of  the 
central  wliite  substance,  but  was  not  gelatinous  like  the  left. 
In  the  pons,  just  imder  the  floor  of  the  fourth  ventricle,  was 
a  small  recent  apoplexy,  the  size  of  a  split-pea. 

!N"one  of  the  current  vascular  or  embolic  theories  explain 
such  a  case  of  brain  softening.  I  think  such  a  disease  is  the 
result  of  morbid  trophic  changes  of  purely  nervous,  and  not 
of  vascular  origin.  Some  of  the  modern  authorities  would 
apparently  deny  the  nerve  tissue  an  inherent  power  to  waste, 
or  disintegrate,  or  become  diseased  or  softened  independently 
of  the  blood  supply  or  the  packing  tissue  changes.  I  believe 
in  no  such  theory.  Over  mental  work  or  worry  does  not 
primarily  affect  the  blood-vessels,  yet  it  causes  brain  changes 
of  the  most  serious  kinds.  Even  when  vascular  changes  are 
found,  I  believe  them  to  be  secondary  in  great  measure  to 
the  alterations  of  nervous  structure.  The  blood-vessels  and 
the  neuroglia  are,  after  all,  the  servants  of  the  brain  tissue 
proper,  and  this  has  not  been  kept  sufficiently  in  mind  in 
some  recent  nerve  pathology. 

On  the  vascular  starvation  theory  of  brain  necrosis  it  has 
been  always  assumed  that  some  mechanical  obstruction  of  a 


102  STATES   OF   MENTAL   DEPRESSION, 

vessel  by  embolism  or  thrombosis  is  required.  I  have  seen 
most  of  a  hemisphere  softened  and  bloodless,  with  every 
vessel  fully  patent.  There  had  evidently  been  a  spasmodic 
closure  of  the  vessels,  a  true  vaso-motor  spasm  of  a  prolonged 
and  complete  kind,  starving  one  hemisphere  of  blood  and 
killing  the  patient.  I  beheve  that  sometimes  happens,  and  is 
the  cause  of  softenings,  apoplexies,  epilepsies,  spasms,  and 
mental  affections  in  different  cases. 

Suicidal  and  Homicidal  Melancholia. — The  question  of  the 
patient  being  suicidal  should  never  in  any  case  of  melanchoHa 
be  left  unconsidered,  and  the  risk  of  his  becoming  suicidal 
should  never  in  any  case  be  left  unprovided  for.  I'J'o  tendency 
to  suicide  exists  at  all  in  many  melanchohcs  from  beginning 
to  end  of  their  disease,  but  it  does  exist  in  some  form  or 
other — in  wish,  intention,  or  act — in  four  out  of  every  five 
of  all  the  cases,  and  we  can  never  tell  when  it  is  to  develop 
in  any  patient.  The  intention  and  the  act  may  come  on 
suddenly,  by  suggestion  from  without  or  witliin,  or  by  the 
sight  of  opportunity  or  means  of  self-destruction.  "Wlien  a 
man  takes  away  his  own  life,  or  even  when  a  serious  attempt 
is  made,  it  is  so  distressing  to  every  one  connected  with  the 
patient,  so  hurtful  to  his  prospects,  and  so  damaging  to  the 
reputation  and  foresight  of  the  doctor  in  charge,  and  so  in 
the  teeth  of  the  radical  medical  principle  to  obviate  the 
tendency  to  deatli,  that  no  pains  should  be  spared  to  guard 
against  its  occurrence.  While  it  prevails  so  commonly  in  all 
forms  of  melanchoha,  there  is  a  variety  of  this  disease  which 
is  specially  characterised  by  the  suicidal  intent  and  impulse, 
and  of  all  the  forms  of  mental  depression  tliis  is  one  of  the 
most  striking  and  most  important.  When  the  love  of  life, 
that  primary  and  strongest  instinct,  not  only  in  man  but  in 
all  the  animal  kingdom,  through  which  continuous  acts  of 
self-preservation  of  the  individual  life  of  every  Kving  thing 
are  performed — when  that  is  lost,  and  not  only  lost  but 
reversed,  so  that  a  man  craves  to  die  as  strongly  as  he  ever 
craved   to   hve,    we   have   then   the    greatest  change  in  the 


STATES   OF   MENTAL  DEPKESSION.  103 

instinctive  and  affective  faculties  of  man  that  is  possible,  and 
"we  have  reached  the  acme  of  all  states  of  mental  depression. 
Suicide  in  some  cases  is  a  desperate  impulse,  in  others  an 
insatiable  hunger,  in  others  a  fixed  resolution  to  be  calmly 
and  deliberately  carried  out,  and  in  others  a  frantic  attempt 
to  escape  imaginary  calamities  or  tortures. 

The  determination  to  commit  suicide  is  in  some  cases  one 
come  to  in  the  calmest  and  most  reasoning  way.  A  patient 
says — "I'm  utterly  miserable.  I'm  not  going  to  recover. 
Why  should  I  live  in  torture  1 "  and  so  determines  to  end  his 
life.  Such  cases  are  nearest  in  character  to  the  suicides 
among  sane  persons  which  MorseUi's  statistics  ^  show  are 
increasing  in  nearly  all  the  civihsed  countries.  I^ext  to  this 
mode  of  arriving  at  the  suicidal  purpose,  in  my  experience, 
come  the  attempts  to  commit  suicide  from  the  motive,  illogical 
as  it  seems,  to  escape  imaginary  torture  or  persecution.  This, 
too,  causes  one  of  the  most  common  mistakes  made  in  not 
taking  precautions  against  it.  A  man  is  desperately  afraid 
he  is  going  to  be  hanged  for  some  imaginary  crime,  and  his 
friends  think  it  would  be  absurd  to  have  anyone  watched 
against  taking  away  his  own  Hfe  who  seems  so  morbidly 
fearful  that  some  one  else  is  going  to  do  it  for  him.  But  this 
is  one  of  the  most  dangerous  class  of  cases.  The  psycho- 
logical condition  of  such  a  person,  when  analysed,  is  found  to 
be  this,  that  there  coexist  a  paralysis  of  the  life-love,  a 
suicidal  longing,  with  delusions  of  persecution  or  torture 
side  by  side.  They  are  mental  symptoms  of  the  same  brain 
disorder.  A  very  suicidal  lady — B.  K. — in  this  state  wrote  a 
friend : — "  If  my  soul  and  body  covld  both  die,  this  would  be 
my  salvation ;  but  no,  this  will  not  be.  0  God  !  how  dreadful 
seems  my  case.  Sadness,  terror,  tortures  intolerable  will  be 
my  portion."  In  other  cases  there  is  a  direct  delusion  or 
hallucination  leading  to  the  act  of  self-destruction.  The 
patient  thinks  himself  too  bad  to  live,  that  he  pollutes  the 
earth,  is  a  source  of  misery  to  his  relations,  that  he  must 
^  Suicide,  Henry  Morselli. 


104  STATES   OF  MENTAL  DEPRESSION. 

sacrifice  himself  to  save  others ;  or  he  hears  voices — of  God, 
of  the  devil,  of  friends  and  enemies,  dead  and  ahve — saying 
to  him,  "  Kill  yourself  ;  "  "  Cut  your  throat;"  or  there  is  a 
longing  for  death  simply,  so  intense  as  to  overpower  all  other 
motives  and  considerations,  without  any  delusion — a  death- 
love  that  acts  as  a  fascination.  Then  there  are  cases  where 
there  is  no  love  of  death  at  all,  hut  rather  a  fear  of  it.  Yet  ■ 
an  ungovernable  morbid  impulse  impels  the  patient  to  commit 
suicide  against  his  will,  and  contrary  to  any  resolution  he  is 
able  to  form.  Then  there  are  cases  where,  without  loss  of 
consciousness,  the  suicidal  feehng  comes  suddenly  on,  as  in 
the  case  of  a  boy  of  six  I  knew,  who  would  suddenly  tell  his 
mother  to  put  away  the  knives  as  he  might  cut  his  throat ; 
at  eighteen  he  had  an  attack  of  adolescent  mania.  Lastly, 
there  is  the  epileptic  suicidal  impulse  while  the  patient  is  in  a 
state  of  false  consciousness,  with  no  memory  of  the  act  after- 
wards at  all.  But  the  last  two  I  shall  treat  of  under  the 
heading  of  impulsive  insanity.  ISTaturally  it  follows,  such 
being  the  immediate  motives  to  suicide,  the  act  is  carried  out 
or  attempted  in  a  great  variety  of  ways.  Sometimes  it  is 
sudden,  the  desire  to  do  it  arising  in  a  moment,  without 
warning ;  in  other  cases,  it  is  led  up  to  by  the  clinical  history 
of  the  case  very  gradually ;  in  other  cases  most  elaborate 
preparations  have  been  made  to  accomphsh  it.  Twice  in 
America — one,  I  think,  in  imitation  of  the  other — men  have 
constructed  an  elaborate  apparatus,  taking  months  to  make, 
by  which  the  contriver  gave  himself  chloroform  first,  and 
when  unconscious  an  axe  was  let  loose  and  chopped  ofi"  his 
head.  In  other  cases  much  cunning  and  mendacity  are  used 
to  throw  friends  off  their  guard,  so  as  to  enable  patients  to 
effect  their  purpose.  As  a  general  rule,  the  more  it  is  talked 
of  by  a  patient  the  less  danger  is  there  of  its  being  carried  out ; 
but  to  this  there  are  exceptions.  In  most  really  serious  cases 
this  is  less  talked  of  by  the  patient  than  any  other  symptom 
of  melanchoha.  The  most  absurd  precautions  are  sometimes 
taken  in  doing  the  act.     Yery  often  patients  take  off  some 


STATES   OF   MENTAL   DEPRESSION.  105 

of  their  clothes  "when  about  to  cut  their  throats.  I  had  a 
patient  once  who,  in  liis  own  house,  arranged  himself  most 
carefully  over  the  seat  of  his  water-closet  before  he  opened  a 
vein  in  his  arm  with  a  penknife. 

Amount  of  Risk. — Yarious  things  determine  the  real  amount 
of  risk ;  the  intensity  of  the  disease ;  the  amount  of  conscious- 
ness and  volition  left ;  the  temperament  of  the  patient ;  the 
means  available;  the  suggestions  offered  in  the  shape  of 
opportunity,  that  is,  the  sight  of  knives,  ropes,  water,  open 
windows,  poison,  which  in  certain  cases  can  rouse  into  activity 
a  till  then  dormant  suicidal  desire ;  and,  above  all,  the  natural 
courage  and  resolution  of  the  patient.  The  effect  of  the  last 
element  is  overwhelmingly  proved  by  the  fact  that  only  one 
woman  commits  suicide  for  every  three  or  four  men  in  all 
countries,  the  suicidal  desire  I  find  being  more  frequent  in 
women  than  men.  There  are  some  hypochondriacal  and 
simple  melancholies  who  are  always  talking  of  suicide,  and 
who  never  go  further  than  talk  and  ostentatious  preparation. 
I  have  referred  to  the  hypochondriac  (A.  L.,  p.  51)  who  tried 
to  hang  himself  by  pulling  liimself  up  a  flagstaff  with  one  end 
of  the  rope  round  his  neck  and  the  other  in  his  hand.  I 
knew  a  patient  alarm  his  friends  by  drinking  a  liniment  wliich 
he  knew  to  contain  only  a  little  Tinct,  Saponis ;  another  who 
went  and  bought  no  less  than  30  yards  of  rope,  hinting  his 
fell  purpose  to  the  shopman  ;  another  who  was  always  tying 
thread  and  garters  round  his  neck,  just  tight  enough  to  make 
a  mark ;  and  many  who  tried  to  end  their  lives  by  holding 
their  breaths.  In  some  suicidal  cases  there  are  curious 
automatic  suicidal  movements  quite  unconsciously  done.  I 
have  always  many  patients  who,  at  times,  put  their  hands  to 
their  throats  and  compress  them  slightly.  Some  patients 
regularly  "  work  at  their  throats  "  in  that  way.  I  have  seen 
continued  in  a  patient,  as  an  automatic  muscular  habit,  the 
mere  organic  memory  of  a  melanchoHc  suicidal  state  wliich 
had  then  passed  away,  the  patient  being  at  the  time  cheerful 
and  convalescent.     So  I  have  seen  patients  gently  strike  their 


106  STATES   OF   MEXTAL   DEPRESSION. 

heads  against  walls,  and  play  with  dinner  knives,  as  if  to  end 
themselves,  long  after  any  real  suicidal  desire  had  gone. 

Metlwds  of  Suicide. — Regarding  the  modes  of  committing 
suicide,  there  are  eight  most  common — drowning,  hanging, 
starvation,  wounds,  firearms,  poisoning,  precipitation  from  a 
height,  and  asphyxia.  But  other  and  rarer  methods  are  as 
diversified  and  original  as  human  imagination  can  conceive. 

Some  things  seem  to  go  contrary  to  the  radical  instincts 
of  human  nature,  e.g.,  going  into  boiling  water,  or  swallowing 
it,  or  putting  a  hot  coal  into  the  mouth  and  attempting  to 
swallow  it.  But  I  have  seen  one  example  of  each  of  all 
these  modes  of  attempted  self-destruction.  "  Each  country," 
says  Morselh,  "has  certainly  its  particular  predilections."  He 
says,  too, — "In  the  choice  of  the  means  of  death  man  is 
generally  guided  by  two  motives — the  certainty  of  the  event, 
and  the  absence  or  shortness  of  sufi'ering."  I  disagree  with 
this.  I  think  he  is  guided  by  the  readiness  and  the  simplicity 
of  the  means  at  hand,  by  the  absence  of  ideas  connected  with 
them  repugnant  to  the  instincts  of  human  nature,  by  his 
natural  temperament,  and  by  the  suicidal  traditions  of  his 
country,  or  race,  or  profession.  In  China  and  Japan  the 
means  used  are  entirely  difi'erent  from  those  in  Europe.  But 
one  fact  is  of  great  practical  and  prophylactic  importance. 
The  same  patient  very  often  sticks  to  one  means  of  suicide. 
A  man  who  wants  to  cut  his  throat  or  drown  himself  will 
frequently  pass  unattempted  innumerable  opportunities  of 
hanging.  Even  the  vanities,  follies,  and  eccentricities  of 
human  nature  come  out  strongly  in  the  modes  of  committing 
suicide.  I  knew  a  man  who  was  very  particular  about  his 
linen,  and  could  not  bear  the  idea  of  cutting  his  throat 
because  it  would  soil  his  shirt  front,  and  people  might  say 
he  had  not  had  on  a  clean  shirt  that  day,  while  he  was  very 
anxious  to  get  poison.  Patients  frequently  starve,  or  attempt 
to  starve,  themselves  in  order  to  terminate  their  Hves ;  yet 
food  is  by  no  means  always  refused  in  insanity  with  that 
direct  object. 


STATES   OF   MENTAL  DEPKESSION,  107 

Modes  of  Forcible  Feeding. — It  may  be  convenient  here  to 
refer  to  the  best  means  of  forcible  feeding.  If  persuasion,  a 
httle  starvation  in  strong  patients,  and  fresh  air  and  exercise 
do  not  make  them  take  food,  patients  will  frequently  masti- 
cate and  swallow  when  it  is  put  into  their  mouths.  From 
very  long  experience  I  say  that  a  liquid  custard  of  new  milk, 
cream,  and  three  or  four  eggs,  flavoured  with  a  dash  of 
nutmeg  or  sherry,  is  the  very  best  and  handiest  form  of 
liquid  diet  at  first,  and  for  a  time  at  least.  If  feeding  has 
to  be  long  continued,  the  best  way  is  to  have  a  big  mortar, 
and  pound  into  a  hquid  form,  with  beef-tea,  the  ordinary 
diet.  Beef,  mutton,  fowl,  fish,  and  vegetables  of  all  kinds 
can  in  this  way  be  liquefied.  Always  add  \  lb.  sugar  to  each 
meal,  a  teaspoonful  of  maltine,  and  half  a  glass  of  brandy, 
and  feed  twice  or  thrice  a  day.  If  the  patient  will  not 
swaUow,  the  simplest  and  most  available  of  all  apparatus  is 
about  6  inches  of  india-rubber  tubing  from  a  baby's  feeding 
bottle,  that  can  be  got  at  any  chemist's,  and  a  small  funnel 
of  any  sort.  With  tliis  latter  inserted  into  one  end  of  the 
tube,  and  the  other  end  well  oiled  and  passed  along  the  floor 
of  the  nares  to  the  pharynx,  we  can  pour  down  the  custard 
in  tablespoonfuls,  and  the  patient  must  swallow  it.  But 
this  mode  of  feeding  won't  do  for  long,  for  patients  soon  get 
into  the  trick  of  expiring  just  as  the  fluid  is  entering  the 
pharynx,  and  so  blowing  it  out  of  their  mouths.  There  are 
now  made  French  red  rubber  elastic  tubes,  hke  longer 
stouter  catheters,  which  can  be  passed  along  the  nasal  cavity 
and  down  into  the  oesophagus  and  so  overcome  this  difficulty. 
A  small  funnel  inserted  into  the  free  end  enables  us  to  pour 
any  kind  of  Uquid  food  into  the  stomach.  If  the  abdominal 
muscles  resist,  and  the  liquid  will  not  flow  down,  then  a 
"  Yellowlees'  bottle  "  attached  enables  one  to  blow  the  food 
into  the  stomach.  This  implies  no  forcible  opening  of  the 
jaws,  and  will  succeed  in  almost  all  the  patients.  I  always 
use  this  method  now,  and  I  am  satisfied  it  is  by  far  the  best. 
But   in   case   this   method   fails,   we   must   use   the  French 


108  STATES   OF   MENTAL   DEPRESSION. 

rubber  tubes  of  large  size  to  be  passed  into  tbe  stomach  by 
the  mouth,  which  must  be  first  opened  by  a  suitable  instru- 
ment (to  be  got  from  all  good  instrument-makers).  Tliis 
moiTth-opener  should  always  be  tightly  wrapped  round  at  the 
points  with  strong  tape  to  protect  the  teeth,  l^ever  bring 
the  steel  in  contact  with  the  teeth.  If  there  is  very  great 
difl&culty  in  opening  the  mouth,  two  openers,  one  put  in  at 
each  side  of  the  mouth,  and  both  screwed  up  at  once,  obviate 
all  difl&culty.  For  such  forcible  feeding  have  plenty  of 
assistance.  Use  a  large  stomach-pump,  or  a  funnel  at  the  end 
of  the  tube  held  above  the  patient's  head,  or  the  bottle 
mentioned,  to  pass  the  hquid  nourishment  into  the  stomach. 
Take  care  the  patient  does  not  get  up  and  tickle  the  throat 
and  vomit  the  food  after  the  meal.  With  good  tubes  and 
instruments,  and  plenty  of  assistance,  the  patient  being 
placed  on  a  bed  or  sofa,  with  his  head  raised,  he  can  be  fed 
quickly  and  easily.  I  seldom  have  any  difficulty.  I  must 
say,  however,  that  I  have  met  with  two  patients  where  I 
could  not  pass  the  French  soft  rubber  tube,  and  where  I  had 
to  use  the  old  stiffer  gum  elastic  tube,  so  that  it  is  well  to 
have  one  on  hand. 

Period  of  Greatest  Danger. — My  experience  is  that  the 
greatest  danger  of  suicide  is  near  the  commencement  of  the 
attack  of  melancholia.  The  impulse  is  then  commonly 
strongest,  and  its  presence  and  danger  is  less  reahsed.  Like 
any  other  disease,  its  intensity  gets  spent  after  a  time.  So 
with  refusal  of  food.  It  is  generally  most  troublesome  at 
the  beginning. 

As  showing  the  contradictory  feelings  in  a  mildly  suicidal 
case,  this  is  the  letter  of  one  (B.  K.) : — "  I  wish  you  would 
come  to  see  me.  I  never  sleep  at  aU  now.  I  am  very  ill, 
and  I  am  in  despair  about  my  soul's  salvation.  I  wish  I  had 
an  opportunity  for  suicide.  I  hope  to  see  you  soon.  I  am 
very  much  afraid  of  hell.  I  am  getting  worse,  and  I  see  no 
chance  of  getting  well.  I  sometimes  wonder  how  much 
money  I  have  lost.     I  am  afraid  of  losing  money  by  being 


STATES   OF   MENTAL   DEPRESSION.  109 

fined  for  blasphemous  writings  or  whisperings  (which  he 
indulged  in  often).  I  wish  I  was  dead.  The  keepers  have 
been  very  kind  to  me.  I  hope  to  live  with  you  soon.  If 
you  lived  in  Edinburgh  I  would  be  very  glad  to  see  you.  I 
am  afraid  of  dying  suddenly.  I  would  be  happier  with  you. 
I  hope  to  be  better  when  you  come.  Write  soon.  I  am 
afraid  of  hell  very  much.  Is  your  health  good  1  Keep 
your  money  safe  beyond  my  reach. — Yours  affectionately." 

Degree  of  Intensity  of  Suicidal  Feeling. — It  is  most  impor- 
tant to  estimate  the  degree  of  intensity  of  the  suicidal  feehng. 
Is  it  obviously  over-mastering  ?  Is  the  power  of  attention 
and  of  reasoning  greatly  impaired  ?  Are  the  natural  habits  or 
propensities  changed?  the  hkings  and  antipathies  interfered 
with  or  reversed  1  Is  the  sense  of  the  ludicrous  gone  ? — But  it 
must  be  remembered  that  the  sense  of  the  ludicrous  may  not 
be  gone,  and  yet  a  serious  suicidal  intent  may  be  present. 
I  have  seen  outbursts  of  gaiety  in  a  suicidal  melancholic. — 
Is  the  capacity  for  ordinary  social  enjoyment  gone?  Are 
the  delusions  wholly  believed  in  and  dominating,  or  only 
partially  so  ?  Is  the  patient  cunningly  trying  to  throw  you 
off  your  guard  ?     Is  he  subject  to  relapses  and  remissions  ? 

The  following  is  a  record  of  one  of  the  most  persistently  and 
strongly  suicidal  cases  I  ever  had  under  my  care  : — 

B.  L.,  a  professional  man,  aged  25,  of  melanchohc  tem- 
perament ;  nervous  and  reserved  but  kindly  disposition  ; 
temperate  and  industrious  habits  ;  had  been  a  hard  student. 
A  cousin  of  liis  mother  and  one  of  his  maternal  great-aunts 
were  insane.  Comes  of  a  professional  family.  There  was  no 
exciting  cause  for  his  illness.  Nine  months  ago  he  got  dull 
and  sleepless.  He  first  thought  he  did  not  do  his  professional 
work  well ;  then,  by  a  natural  transition,  as  his  disease 
acquired  more  power,  that  he  had  committed  some  crime  and 
ought  to  die,  and  that  his  soul  was  lost.  He  took  a  poisonous 
dose  of  belladonna  with  suicidal  intent  before  admission.  He 
had  fallen  off  in  bodily  strength  and  flesh.  On  admission  he 
was   perfectly    coherent,  and   his   memory  good,  but   much 


110  STATES   OF  MENTAL  DEPRESSION. 

depressed,  with,  no  interest  in  anything,  and  with  the 
delusions  above-mentioned.  In  spite  of  treatment,  which 
consisted  of  nutritious  food  and  tonics,  and  attempts  to  get 
him  employed  and  his  attention  aroused  to  healthy  objects  of 
interest,  he  got  steadily  worse.  His  pulse  was  weak,  his 
temperature  Ioav,  his  muscles  flabby,  his  complexion  pale,  and 
his  bowels  costive.  He  walked  rapidly  about,  and  could  not 
sit  down  long  and  settle  himself.  He  said  he  was  troubled 
much  with  seminal  emissions,  and  this  seemed  to  depress  him 
further.  He  had  a  dislike  of  animal  food.  He  made  in- 
numerable attempts  at  suicide  in  quiet,  reasoning,  dehberate 
ways.  He  put  his  fingers  down  his  throat ;  he  swallowed 
berries  of  the  Arbor  vitce  picked  in  the  grounds  ;  he  swallowed 
-  eighty-two  small  stones  gathered  in  the  gravel  walks  (weigliing 
twenty-four  ounces),  and  passed  them  without  doing  him  any 
harm ;  he  tried  to  push  a  nail,  picked  up  and  secreted  for  the 
purpose,  into  his  heart  j  he  seized  a  bottle  of  whisky  one  day 
and  drank  part  of  it.  Even  when  intoxicated  with  this  he 
was  miserable  ;  and  his  dreams,  he  said,  were  only  a  httle 
less  depressing  than  his  waking  thoughts,  which  were  always 
that  he  was  wronging  everyone  by  allowing  himself  to  hve, 
and  that  he  ought  to  take  away  his  life  and  so  end  his  misery 
and  lessen  his  punishment  in  the  other  world.  He  refused 
his  food  for  a  time,  and  had  to  be  fed  with  the  stomach 
pump.  I  was  singularly  unfortunate  in  the  attendants  I 
placed  in  charge  of  him,  for  they  got  very  careless,  and  one 
or  two  I  dismissed  on  his  account.  He  was  so  quiet  and 
reasonable  and  nice  a  man,  and  tried  so  successfully  to  throw 
them  off  their  guard,  and  his  attempts  were  so  carefully 
planned  that,  no  doubt,  a  man  unacquainted  with  disease 
from  the  physician's  point  of  view  Avas  very  apt  to  abate  liis 
watchfulness.  An  attendant  will  be  very  alert  for  a  few 
weeks,  but  when  it  comes  to  months,  and  when  the  man  he 
has  to  watch  seems  as  reasonable  as  he  is  himself,  and  is  quiet, 
it  is  almost  impossible  to  get  one  who  will  not  give  such  a 
man  a  chance  some  time.     The  whole  mental  energy  of  B.  L. 


STATES   OF   MENTAL  DEPRESSION.  Ill 

was  employed  all  the  time  in  scheming  suicide.  And  when 
such  a  man  is  a  doctor,  it  simply  is  a  question  of  how  long  he 
wiU  take  to  get  a  chance.  He  drank  some  turpentine  used 
for  polishing,  once,  and  nearly  died.  He  was  weak  and 
threatened  with  bed-sores,  and  his  attendant  got  a  solution  of 
guttapercha  in  cliloroform  to  paint  over  his  skin.  B.  L. 
seized  the  bottle  and  drank  a  quantity  of  it.  "We  had  to  use 
artificial  respiration  by  Sylvester's  method  and  the  interrupted 
current  for  14 J  hours,  when,  to  our  surprise  and  dehght, 
he  began  to  breathe,  and  told  us  to  "  go  to  hell.''^  That  case 
taught  me  many  lessons,  practical  and  medical.  I  have  never 
trusted  one  attendant  continuously  on  duty  in  such  a  case 
since.  I  have  never  believed  anyone  to  be  dead,  since  my 
experience  of  B.  L.'s  resuscitation,  merely  because  he  could 
not  breathe  and  liis  pulse  could  not  be  felt.  Six  months 
after  admission  poor  B,  L.  died  of  slow  exhaustion.  Food 
would  not  nourish  him ;  stimulants  would  not  rouse  him. 
The  disease  arrested  all  his  trophic  energy.  He  determined 
to  die,  and  seemed  to  accomphsh  his  object  by  the  strength  of 
his  volition. 

The  following  was  a  case  of  acute  suicidal  melancholia 
coming  on  suddenly,  caused  hy  prolonged  affective  strain,  anxiety, 
and  leant  of  sleep,  with  intense  suicidal  feeling,  and  many 
attempts ;  no  sleep ;  exhaustion  and  death  in  a  fortnight  :^ 

B.  M.,  set.  55,  a  man  of  a  melancholic  temperament, 
nervous  diathesis,  rather  over-sensitive  disposition,  great 
intellectual  power,  and  good  education.  For  months  he  had 
had  too  little  sleep,  and  very  great  domestic  anxiety.  This 
did  not  seem  to  tell  on  him  till  a  sudden  outbreak  of  intense 
melanchoHa,  with  suicidal  feehng,  came  on  him  without  any 
outward  warning.  But,  no  doubt,  he  was  a  man  of  immense 
power  of  inhibition,  who  had  the  capacity  to  work  his  brain 
up  to  the  point  of  complete  exhaustion,  and  also  conceal  from 

^  A  full  account  of  this  case  was  published  by  Dr  J.  J.  Brown,  then 
one  of  my  assistants,  in  the  Edinburgh  Medical  Journal  for  November 

1874. 


112  STATES   OF   MENTAL   DEPRESSION. 

others  any  evidence  that  he  was  doing  so.  This  phenomenon 
is  very  often  seen  in  "women  nursing  those  dear  to  them,  or 
"  keeping  up  "  themselves  and  others  under  loss  or  calamity. 
They  look  cheery  up  to  the  last,  and  do  their  work,  but  they 
break  down  suddenly,  and  sometimes  incurably.  He  asked 
one  morning  that  his  razors  should  be  put  away,  and  within 
an  hour  or  two  he  had  entirely  lost  his  power  of  self-control, 
gave  expression  to  the  intensest  melanchohc  delusions — that 
he  was  too  wicked  to  hve,  and  could  not  hve ;  that  he  was 
lost,  ruined,  &c.,  &c.  When  placed  in  charge  of  attendants, 
as  he  was  at  once,  he  made  many  and  desperate  attempts  at 
suicide,  so  that  he  could  not  be  left  for  a  moment.  He  could 
not  be  roused  to  attend  to  anything  ;  he  was  restless,  moaned, 
and  never  expressed  any  interest  again  in  his  wife,  or  family, 
or  concerns.  There  was  a  sudden  paralysis  of  his  love  of  life, 
of  wife,  and  of  children — of  his  interest  in  anything  but  his 
delusions.  His  tongue  was  furred  and  tremulous,  his  facial 
expression  that  of  despair,  his  pulse  feeble,  his  temperature 
100°,  his  appetite  gone,  his  bowels  costive,  and  his  skin  ill- 
smeUing.  He  never  seemed  to  rally,  and  died  within  a 
fortnight  of  the  acute  brain  condition,  though  he  had  every 
care  and  attention,  with  plenty  of  food  and  stimulants  and 
nursing.  The  cells  of  the  grey  matter  of  his  convolutions 
were  found  extensively  degenerated. 

Frequency  of  the  Suicidal  Impulse. — The  prevalence  of  the 
suicidal  tendency  in  melanchoHa  can  only  be  correctly  brought 
out  by  taking  large  numbers  of  cases.  I  have  taken  the  last 
729  cases  of  melanchoHa  under  treatment.  These  were  from 
all  classes  of  society,  and  this  is  a  valuable  point  in  the 
Morningside  Asylum  statistics,  as  compared  with  those  in  an 
asylum  for  paupers  only.  The  disease  in  all  those  patients 
was  decided  and  marked,  otherwise  the  patients  would  not 
have  been  sent  to  the  Asylum.  All  the  very  mild  cases  would 
be  kept  at  home,  and  many  of  the  decided  cases,  too,  among 
the  richer  classes.  In  regard  to  melanchoHcs  treated  at  home, 
I  have  no  means  of  ascertaining  the  prevalence  of  the  suicidal 


STATES   OF   MENTAL  DEPRESSION.  113 

feeling,  and  it  must  be  kept  in  mind  that  many  of  my  patients 
are  sent  to  the  Asyhim  on  account  of  their  suicidal  tendencies 
chiefly,  and  but  for  these  would  have  been  at  home.  It  may 
fairly  be  regarded,  then,  as  far  more  common  among  asylum 
melancholies  than  among  those  labouring  under  the  disease 
out  of  asylums.  Among  those  729  cases  there  were  283,  or 
about  two-fifths  (39  per  cent.),  who  had  actually  attempted  to 
commit  suicide.  In  many  cases,  no  doubt,  the  attempts  could 
scarcely  be  regarded  as  being  very  serious.  In  addition  to 
this  number  there  were  301  cases,  or  two-fifths  more,  that 
had  spoken  of  suicide,  or  given  some  indication  that  it  had 
been  in  their  minds.  That  makes  584  out  of  729  melan- 
cholies, or  four  out  of  five  of  the  whole,  that  were  more  or 
less  suicidal.  K^o  wonder,  therefore,  that  the  loss  and  perver- 
sion of  the  instinct  of  the  love  of  life  is  regarded  as  one  of 
the  chief  symptoms  of  melanchoHa.  I  am  quite  sure,  how- 
ever, from  what  I  know  of  the  disease,  that  the  actual  risk 
of  suicide  being  seriously  attempted  or  accomphshed  is  much 
less  than  those  figures  would  seem  to  show.  The  really 
typically  suicidal  cases,  in  whom  the  desire  to  die  is  very 
intense  and  the  chief  symptom  present,  any  one  of  whom 
would  certainly  put  an  end  to  his  hfe  if  he  had  the  oppor- 
tunity, are  not  so  frequent.  As  near  as  I  can  estimate,  one 
melanchohc  in  twenty  only  is  of  this  intense  and  very  danger- 
ous kind. 

There  is  one  peculiarity  about  the  suicidal  feeling  which  it 
is  well  to  keep  in  mind,  and  that  is  its  liabihty  to  return 
suddenly  or  to  be  called  up  by  the  sight  of  means  of  self- 
destruction.  I  had  a  patient  who  was  all  right  so  long  as  he 
did  not  see  a  knife.     That  set  up  the  demon  in  him  at  once. 

Homicidal  Feeling. — The  homicidal  feeling  is  much  rarer  in 
melancholia  than  the  suicidal.  They  frequently  coexist ;  but 
in  some  few  cases  the  homicidal  feehng  exists  alone  without 
the  other.  At  the  beginning  of  acute  alcoholism  we  all  know 
how  common  are  those  tragedies  that  shock  us  in  our  news- 
papers, men  killing  their  wives  and  children,  and  then  tliem- 

H 


114  STATES   OF  MENTAL   DEPEESSION". 

selves.  "We  shall  also  see  that  in  puerperal  insanity  there  is 
a  strong  tendency  in  many  of  the  cases  towards  child-murder ; 
but,  apart  from  those  two  special  forms,  only  a  few  melan- 
cholies have  homicidal  feelings,  of  which  the  following  case  is  an 
example.  She  had,  too,  hallucinations  of  hearing  voices  telling 
her  how  to  commit  suicide,  and  she  made  a  homicidal  attempt : — 
B.  P.,  aet.  30.  Widow ;  of  a  sanguine  temperament ;  frank 
and  cheerful  disposition;  temperate  and  industrious  habits. 
First  attack.  Cause :  annoyance  at  some  legal  proceedings 
three  days  ago.  Became  depressed,  very  restless,  sleepless, 
and  her  appetite  disappeared.  She  began  to  think  her 
children  were  murdered  and  that  people  were  going  to  kill 
her.  Whenever  you  see  such  delusions,  look  out  to  prevent 
suicide.  It  is  a  most  common  accompaniment.  She  had 
hallucinations — hearing  voices  telHng  her  to  commit  suicide, 
which  she  attempted  by  drowning.  Had  been  taken  to  the 
pohce-office  on  emergency,  and  was  at  once  sent  to  the  Asylum. 
On  admission  she  suffered  from  intense  mental  depression, 
crying,  saying  she  had  been  drugged  at  the  police-office,  and 
by  a  servant.  She  said  that  a  chimney-can  turning  with  the 
wind  said  to  her — "  Drown  yourself,  prepare  yourself,  drown 
yourself."  She  was  excited  and  restless  in  manner,  and  jerky 
in  her  muscles.  She  could  answer  questions,  and  her  memory 
was  not  gone.  Her  expression  was  depressed,  suspicious,  and 
alarmed ;  her  skin  muddy  and  spotted ;  pupils  unequal  j  eyes 
ghstening;  was  fat  and  muscular;  tongue  furred;  bowels 
constipated;  appetite  gone;  refused  food  absolutely;  was 
menstruating.  Temperature,  100°'l ;  pulse,  108.  Was  rest- 
less the  first  night,  which  she  spent  in  the  dormitory  with  the 
attendant,  who  twice  during  the  night  sent  a  report  about  her 
to  the  assistant-physician.  At  5.30  a.m.  next  morning  she 
made  a  most  severe  homicidal  attack  on  the  attendant,  nearly 
strangling  her.  Her  motive  for  this  was  not  expressed.  It 
might  have  been  a  pure  homicidal  impulse,  or  it  might  have 
been,  and  I  think  it  was,  from  the  delusion  that  the  attendant 
was  going  to  murder  her.     The  assistant-physician  after  tliis, 


STATES   OF   MENTAL  DEPKESSION.  115 

finding  that  it  was  to  be  a  continuous  struggle  with  the 
attendants,  had  her  placed  in  a  bedroom  alone,  with  the 
shutters  locked  and  everything  made  secure,  as  he  thought, 
with  an  attendant  to  look  in  every  ten  minutes.  He  reported 
this  to  me,  and  I  approved  of  the  mode  of  treatment.  She 
refused  breakfast,  breaking  her  dishes,  and  fighting  with  the 
attendants.  She  was  seen  at  12.30  or  12.35  by  the  attendant 
lying  quietly  in  bed,  but  at  12.45  it  was  found  she  had  hanged 
herself  to  the  shutter  bar,  which  had  not  been  properly 
constructed,  with  a  piece  of  her  sheet,  her  feet  being 
on  the  ground.  The  efforts  at  artificial  respiration  were 
unavailing. 

This  is  an  example  of  an  acute  suicidal  and  homicidal 
melancholia,  the  worst  of  all  cases  to  manage.  If  you  keep 
attendants  with  such  a  patient  there  is  a  struggle  and  much 
danger  to  both ;  if  you  place  him  alone  there  is  always  some 
risk  of  suicide.  What  I  do  now  is  to  put  on  such  a  patient 
clothing  of  strong  untearable  linen,  to  give  for  bedding 
blankets  quilted  in  soft  untearable  canvas,  and  put  him  in  a 
room  padded  if  necessary,  hghted  and  with  an  inspection 
opening,  an  attendant  being  outside  the  door.  It  will  be  seen, 
from  the  temperature  and  whole  conditions,  that  such  a  con- 
dition has  many  of  the  characters  of  an  acute  disease.  Such 
acute  symptoms  do  not  usually  last  long.  If  we  can  tide 
over  the  first  week  or  two,  we  then  expect  all  the  symptoms 
to  abate.  The  hallucinations  of  hearing  in  such  a  case  may 
disappear,  and  are  not  of  such  grave  import  in  prognosis  as  in 
less  acute  cases.  The  unspeakable  agony  which  such  cases  may 
sufi'er  was  well  illustrated  in  B.  P.  A.,  a  man  of  25,  who  had 
led  a  good  life  and  taken  a  high  place  by  examination  in  his 
profession,  but  who  had  been  attacked  by  acute  suicidal 
melancholia.  The  patient  often  needed  three  and  four  men 
to  manage  him  when  rolling  about  on  the  floor  of  the  padded 
room.  In  the  fearful  agony  this  was  his  prayer  to  the  devil 
— "  Oh,  devil,  come  and  take  me  !  Oh,  devil,  come  and  take 
me !     Oh !  oh !  oh  !  oh !     Are  you  asleep  ?     Oh,  devil !  devil ! 


116  STATES   OF   MENTAL  DEPRESSION. 

the  judgment  day  has  come.  Oh,  devil,  take  me  !  Oh,  I 
have  no  will !  I  feel  sick !  Oh,  devil,  take  me !  Thou 
knowest  all  about  me !  Oh,  come  here  or  I'll  kill  myself ! 
Bloodthirsty  devil !  damned  devil !  pull  down  the  house ! 
These  men  (the  attendants  and  doctor)  have  come  for  me  !  " 
&c.,  &c.  Eepeated  hypodermic  injections  of  hyoscine  of  ^g- 
gr.,  with  doses  of  sulphonal  in  20  grs.  in  between,  had  to  be 
used  at  first  to  produce  a  sedative  effect  on  his  brain.  But, 
then,  all  this  agonised  dehrium  scarcely  sounds  much  worse 
than  Carlyle's  " semi-dehrium  sad  as  Golgotha,"  his  "spectre 
cliimeeras,"  "bottomless  abysses,"  "  Gehenna  within,"  "spectre 
fighting,"  and  his  "mad  primeval  discord  "  in  Sartor  Resartus. 
The  homicidal  impulse  in  a  sHghter  form  is  more  common. 
I  have  now  two  ladies  under  my  care — B,  Q.  and  B.  R. — 
who  kick,  and  pinch,  and  strike  their  attendants  and  fellow- 
patients,  declaring  they  cannot  help  it.  One  of  them,  B.  Q., 
has  the  suicidal  impulse  too,  and  strikes  her  head  and  breast. 
She  cries  to  be  put  in  a  strait  waistcoat  to  prevent  this.  I 
tried  this  once,  but  it  had  no  good  effect,  and  it  gave  her  no 
more  sense  of  security,  and  she  did  not  sleep  any  better.  In 
the  other  case,  B.  R.,  she  only  has  the  homicidal  feeling  in 
the  morning.  In  the  evening  she  is  quite  lively,  dancing, 
and  playing  on  the  piano,  and  smihng.  The  homicidal  f  eehng 
seems  a  reversion  to  the  human  instinct  of  slaughter  and 
destruction  that  is  so  strong  in  all  savage  peoples,  and  is  seen 
in  most  men  when  enraged.  I  had  a  case  in  whom  it  seemed 
to  result  from  an  excessive  production  of  motor  energy  in  the 
nerve  centres,  for  any  mode  of  expending  this — by  tearing  his 
clothes,  digging  in  the  garden,  fighting,  or  gymnastics — -would 
relieve  his  homicidal  feeling  for  the  time.  Such  a  case  is 
very  analogous  to  the  physiological  instinct  of  breaking  things 
in  children.  Many  of  the  excited  melanchohcs  tear  and  break 
things,  fight,  and  attack  those  near  them.  My  experience  is 
that  not  more  than  one  in  fifty  melanchohcs  is  homicidal  in 
any  degree,  and  not  more  than  one  in  a  hundred  is  dangerously 
so ;  but  when  the  suicidal  and  homicidal  tendencies  are  com- 


STATES   OF   MENTAL  DEPKESSION.  117 

bined  in  a  strong  degree,  such,  a  patient  is  worse  to  manage 
and  more  unsafe  than  any  other. 

Anomalous  Cases. — It  must  always  be  remembered  that  a 
large  number  of  patients  do  not  conform  strictly  to  any  of 
those  varieties  of  melancholia,  and  may  pass  from  one  variety 
into  another,  or  have  the  characters  of  two  or  even  three  of 
the  varieties.     The  folloioing  is  such  a  case  : — 

B.  S.,  set.  50.  Single.  !N"o  occupation.  Fair  education. 
Disposition  reserved.  Habits  correct  and  temperate.  One 
previous  attack  of  melancholia,  duration  under  a  week, 
treated  at  home.  No  hereditary  predisposition  to  insanity  or 
other  nervous  disease.  Predisposing  cause  :  previous  attack. 
Exciting  cause :  change  of  life.  First  mental  symptoms : 
had  some  domestic  grief  which  greatly  upset  her ;  became 
unsettled  and  depressed,  and  assigned  groundless  reasons  for 
her  grief.  Has  since  become  taciturn,  and  refused  food  for 
two  days;  sleepless;  not  epileptic,  suicidal,  or  dangerous 
Duration  of  existing  attack :  six  days.  Great  depression, 
constant  restlessness,  moaning  and  complaining,  taciturnity 
when  questioned,  refusal  of  food  and  medicine. 

On  admission :  great  depression,  will  not  answer  a  single 
question,  keeps  constantly  moaning  and  crying  "Oh!  oh!" 
looks  very  miserable,  wanders  about  the  room  incessantly 
wringing  her  hands.  Memory  and  coherence  cannot  be 
tested ;  will  not  attend  to  questions.  Seems  to  have  delusions 
of  a  melancholic  character.  Is  a  thin  middle-aged  lady. 
Muscularity  and  fatness  poor.  Appetite  absent.  Pulse  108, 
regular  but  small.  Temperature  9 9° "4.  General  bodily 
condition  very  weak. 

First  night  in  the  Asylum  was  very  restless,  kept  up  a 
constant  wail  of  "  Oh  !  oh  !  "  Could  with  difficulty  be  got  to 
swallow  a  little  fluid  food.  "  Typhoid "  expression ;  very 
sallow  look ;  dark  rings  round  eyes ;  dry  scaly  Hps ;  tempera- 
ture 99°"2.  This  state  continued  and  increased  for  about  a 
fortnight  without  improvement.  Very  sleepless;  constant 
piercing  wail,  very  distressing  to  other  patients.     Her  weak- 


118  STATES   OF   MENTAL   DEPKESSION. 

ness  was  extreme.  Slie  was  entirely  confined  to  hei  and  fed 
every  half  hour  "witli  liquid  food,  milk,  eggs,  beef -tea,  and  a 
large  quantity  of  wine.  She  then  began  to  improve  and  was 
much  better  in  the  mornings,  and  got  worse  in  the  afternoons. 
Could  be  induced  to  speak  intelligently  ;  looked  less  depressed; 
took  a  fair  quantity  of  food;  slept  better.  Within  another 
week  she  was  quite  convalescent,  gaining  in  flesh  and  strength 
very  rapidly.  At  the  same  time  desquamation  occurred  (this 
I  have  seen  in  several  patients  after  such  short  acute  attacks). 
Still  a  want  of  appetite.  Two  weeks  later  sent  out  on  pass. 
Appetite  and  general  health  improved.  Eesidence  in  Asylum, 
four  weeks  and  ten  days.  She  had  a  relapse  four  years 
afterwards,  and  was  admitted  with  the  same  symptoms,  and 
in  spite  of  all  treatment,  died  in  five  days.  Temperature  often 
102° "5;  was  fed;  got  abundant  stimulants.  Xo  pathological 
appearances  beyond  congestion  were  found  in  her  brain. 

There  are  a  few  cases  of  depressed  feeling  ivWi  exalted  in- 
tellectual condition.  Many  patients  exaggerate  their  former 
happiness,  wealth,  and  position  by  way  of  contrast  to  their 
present  misery.  I  had  a  woman  in  excited  melanchoha, 
groaning  all  the  time,  who  fancied  herself  a  queen;  another 
who  had  immense  wealth.  Some  few  of  the  cases  are  of  the 
nature  of  what  the  French  caU  megalomania,  that  is,  an 
expansive  grandiose  exalted  state  of  mind,  coupled  with  ideas 
of  persecution,  and  with  depressed  feehng. 

The  Inception  of  Melancholia. — It  begins  in  most  patients 
as  simple  lowness  of  spirits,  and  lack  of  enjoyment  in  occupa- 
tion and  amusement,  and  loss  of  interest  in  hfe.  This  may 
be  premonitory  of  the  disease  by  months,  or  even  years,  and 
happy  is  the  man  who  then  takes  proper  warning  and  adopts 
proper  treatment.  The  next  stage  is  that  of  the  simple 
melancholia  described  in  A.  B.'s  case  (p.  33),  and  tliis  may  be 
of  long  or  short  duration,  and  may  pass  into  one  of  the  other 
and  more  serious  varieties.  As  a  general  rule  the  hypo- 
chondriacal variety  is  longest  and  slowest  in  inception.  I 
have  seen  the  delusional,  the  suicidal,  and  the  excited  varieties 


STATES   OF   MENTAL   DEPRESSION.  119 

fully  developed  within  a  week  of  the  commencement  of  the 
first  symptoms,  but  this  is  rare,  I  have  seen  the  loss  of  self- 
control  take  place  quite  suddenly,  a  man  being  calm  exter- 
nally, though  dull,  in  the  early  morning,  and  by  10  o'clock 
A.M.  in  the  acutest  stage  of  suicidal  and  excited  melancholia. 
Many  patients  exercise  self-control  strongly  for  a  time,  and 
then  at  once  lose  it.  This,  however,  is  not  common.  The 
duration  of  the  disease  previous  to  the  admission  of  the  case 
into  an  asylum  is  a  good  test  of  the  rapidity  of  progress  of 
the  disease  in  its  full  stages  up  to  the  time  that  self-control 
was  so  lost  as  to  require  treatment  and  restraint  in  an 
institution.  Of  365  cases  in  which  information  on  this  point 
was  obtained,  40  per  cent,  had  been  melancholic  for  periods 
under  a  month  before  admission,  16  per  cent,  for  periods 
from  one  to  three  months,  8  per  cent,  from  three  to  six,  and 
the  remaining  36  per  cent,  over  six  months. 

The  delusions  in  many  cases  take  their  shape,  if  not  their 
origin,  in  painful  or  disagreeable  sensations  in  the  organs, 
which  are  misinterpreted  by  the  disordered  mind,  and 
attributed  to  wrong  causes.  Continuous  attention  to  morbid 
feeHngs  is  very  apt  to  aggravate  them,  and  they  often 
originate  from  purely  mental  suggestions.  In  some  cases  a 
paralysis  of  the  consciousness  of  natural  affection  is  the  first 
symptom  of  melanchoHa,  and  the  patients,  thinking  that  they 
no  longer  love  their  children,  get  depressed.  I  have  known 
in  many  cases  a  craving  for  stimulants  to  be  the  first  symptom. 
I  knew  a  lady  in  whom  this  was  so  each  time  she  became 
melancholic,  which  she  did  at  each  pregnancy  and  at  the 
climacteric  period. 

The  ages  at  which  melancholia  comes  on  are  more  advanced 
ages  on  the  whole  than  in  the  case  of  mania  (see  Plate  Y.). 
Four  per  cent,  only  come  on  under  20 ;  only  20  per  cent, 
under  30.  The  largest  proportion  of  cases  in  any  one 
decennial  period  (25  per  cent.)  occurred  between  40  and  50, 
while  there  was  23  per  cent,  between  30  and  40,  18  per  cent, 
between  50  and  60,  and  14  per  cent,  over  60, 


120  STATES   OF   aiENTAL  DEPRESSION. 

Bodily  Symptoms  and  Precursors  of  Melancliolia,  and  the 
Relationship  of  Mental  to  Bodily  Pain. — I  tMnk  it  a  reason- 
atle  inference  that  tlie  condition  of  the  brain  cortex  which 
directly  causes  the  subjective  feeKng  of  bodily  pain  from  a 
burn  of  the  finger  is  the  same  as  that  which  causes  the  pain 
of  typical  neuralgia  of  central  origin,  and  that  the  cortical 
state  cannot  be  very  difi'erent  in  a  woman  who  is  prostrated 
with  grief  on  account  of  the  loss  of  a  child  from  that  of 
another  who  is  equally  prostrated  with  grief  from  the  delusion 
that  she  has  by  her  misconduct  imperilled  the  salvation  of 
her  family.  Meynert's  theory  of  the  cause  of  the  pain  in  aU. 
these  four  cases  is  that  we  have  a  strong  inhibition  in  the  grey 
matter  causing  increased  arterial  pressure,  and  "  dyspnoetic  " 
phases  of  nutrition  of  the  tissue,  this  being  roused  by  sensory 
impressions,  or  by  recollections  of  painful  impressions,  or  by 
processes  of  thought  exciting  psychical  pain.  Whenever  we 
have  strong  inhibition  exercised  by  the  cortex,  it  is  attended 
by  depressed  emotion. 

There  can  be  no  doubt  whatever  as  to  the  close  connection 
of  bodily  and  mental  paiu,  whether  the  mechanism  of  their 
production  in  the  cortex  is  the  same  or  not.^  Chnically  they 
are  closely  related,  and,  in  my  opinion,  they  are  really  parts 
of  the  same  disease.  All  sorts  of  sensory  disturbances  are 
connected  with  melanchoha.  They  commonly  precede  it ; 
they  sometimes  accompany  it,  and  they  often  alternate  with  it.' 
One  patient  will  suffer  from  ordinary  neuralgia  for  long 
before  the  emotional  pain  comes  on ;  another  will  have 
creeping  feelings  or  "indescribable  "  sensations  in  the  head; 
others  will  have  a  sense  of  fulness  there,  or  a  sense  of  weight 
or  of  emptiness.  Spinal  pains  and  discomfort,  sciatica, 
changed  feehngs  as  to  heat  and  cold,  sensations  of  sinking  in 
the  epigastrium,  I  have  known  to  usher  in  an  attack  of 
melancholia.  During  the  attack  it  is  common  for  patients  to 
have  hallucinations  of  the  senses.     One  lady  told  me  she  saw 

^  See  the  Author's  Address  as  President  of  the  Section  of  Psychology, 
Brit.  Med.  Assoc.  Meeting,  Aug.  1886,  Brit.  Med.  Jour.,  Aug.  1886. 


STATES   OF   MENTAL   DEPEESSION.  121 

the  water  in  her  bath  blood  red,  and  that  stationary  objects 
and  persons  would  appear  to  enlarge  and  diminish  as  she 
looked  at  them.  Food  often  tastes  bitter,  or  as  if  "  poisoned." 
Some  patients  feel  as  if  their  bodies  or  their  limbs  were 
unusually  large  or  very  small,  or  that  they  could  not  move 
again  if  they  tried.  There  is  a  close  hereditary  con- 
nection between  neuralgia  and  melanchoha.  For  prophy- 
laxis attention  to  sensory  disturbances  in  those  prone  to 
raelanchoHa  has  a  special  value.  Many  attacks  might  thus,  I 
beheve,  be  averted. 

The  premonitory  bodily  symptoms  that  I  have  most  com- 
monly met  with  have  been  headaches,  neuralgia,  confused 
feelings  in  the  head,  want  of  appetite,  indigestion,  costiveness, 
a  feehng  of  weariness  and  languor,  in  some  cases  restlessness, 
in  others  "biliousness,"  oxaluria,  and,  above  all,  the  two 
symptoms  of  sleeplessness  and  loss  of  body  weight.  When 
the  'mental  symptoms  become  fairly  developed,  the  headache 
and  neuralgia,  if  present,  usually  disappear,  and  we  have 
instead  a  brilliancy  of  the  eye,  a  tendency  for  the  temperature 
to  rise  a  httle  at  night,  a  depression  or  some  other  change  in 
the  facial  expression,  a  furred  tongue,  which,  in  four  cases 
out  of  five,  is  neurotic,  resulting  from  the  deficient  innervation 
of  the  stomach.  The  want  of  appetite  often  becomes  a  re- 
pugnance to  food,  the  sleeplessness  becomes  complete,  the 
constipation  great;  in  about  15  per  cent,  there  is  a  tempera- 
ture over  99°'5.  The  pulse  rate  often  rises  in  a  most 
unaccountable  way.  It  is  common  to  have  it  100  or  even 
120  with  no  corresponding  rise  of  temperature.  One  can 
only  attribute  it  to  the  cortical  excitement.  Taking  365 
cases  at  random,  I  found  constipation  in  50  per  cent.,  sleepless- 
ness in  60  per  cent.,  want  of  appetite  in  60  per  cent.,  pyrexia 
in  15  per  cent.,  and  hallucinations  of  the  senses  in  25  per 
cent. ;  epigastric  pain  and  sinking  in  a  few,  headaches  and 
sensations  of  binding,  of  weight,  and  emptiness  in  the  head  in 
a  few,  heart  disease  in  a  few,  suppression  of  discharges  in  a 
few,  disappearance  of  skin  disease  in  a  very  few.     Taking  the 


122  STATES    OF   MENTAL   DEPEESSION. 

general  bodily  health  and  condition,  I  find  I  had  put  36  per 
cent,  as  being  in  fair  general  bodily  condition  on  admission,  57 
per  cent,  as  weak  and  in  bad  condition,  and  7  per  cent,  as  very 
weak  and  exhausted.  The  heart's  action  is  markedly  aifected 
in  all  the  acute  cases  and  in  many  of  the  others.  In  the  former 
the  condition  of  hyperaction  in  the  brain  seems  to  exercise  an 
inhibitory  influence  on  the  cardiac  motor  innervation,  causing 
the  pulse  to  be  small,  the  arterial  tone  to  be  low,  and  the 
capillary  circulation  to  be  very  weak  indeed.  Those  are  the 
cases  in  which  the  use  of  digitalis,  strophantus,  and  iron  is 
often  very  useful.  The  skin  is  in  some  of  the  acute  cases  greasy, 
perspiring,  and  ill-smeUing.  In  most  patients,  however,  it 
is  dry,  harsh  feehng,  and  non-perspiring.  Sometimes  we 
have  boils — a  good  sign  often — and  subacute  inflammations. 
Bevan  Lewis  ^  has  shown  that  the  reaction  time,  especially  as 
to  optic  stimuh,  is  markedly  prolonged  in  melanchoHa. 

Causation  of  Melancholia. — The  causes  of  the  disease  are 
always  popularly  supposed  to  be  some  calamity,  some  affliction, 
some  remorse  or  religious  conviction,  that  has  produced  grief 
and  sorrow.  As  physicians,  we  know  how  utterly  far  this  is 
from  the  truth.  If  I  were  asked  my  opinion,  I  should  say 
without  hesitation  that  more  melancholia  results  from  innate 
brain  constitution,  than  from  all  outside  calamities  and  afflic- 
tions of  mankind  put  together.  If  a  man  has  a  well-consti- 
tuted brain,  he  will,  like  Job,  bear  calmly  aU  the  aflhctions 
and  losses  that  the  spirit  of  evil  can  invent  for  him.  It  is 
impossible  to  bring  on  melancholia  in  such  a  man.  That 
needs  some  innate  weakness,  some  predisposition,  some  poten- 
tiahty  of  disease,  some  trophic  or  dynamical  defect.  The 
friends  of  melanchohc  patients  wiU  always  assign  an  outside 
cause  for  their  disease.  To  them  the  occurrence  of  such  a  state 
of  matters  without  some  manifest  cause  seems  an  impossibihty. 
Whoever  saw  a  newspaper  account  of  a  suicide  without  either 
a  cause  being  stated  or  a  remark  implying  that  there  must 
have  been  some  outside  "  cause "  1  A  hereditary  predis- 
1  02).  cit.,  p.  135. 


STATES   OF   MENTAL   DEPEESSION.  123 

position  to  mental  disease  was  admitted  in  about  30  per  cent. 
of  the  cases  of  melancholia  sent  to  the  Eoyal  Edinburgh 
Asylum,  but  that  is  very  far  from  representing  the  truth. 
I  have  no  official  statistics  on  the  point,  but  my  general 
experience  agrees  with  that  of  others,  that  states  of  depression 
of  mind  are  hereditary  more  than  most  morbid  mental 
symptoms.  I  have  known  several  famihes  where  for  four 
generations  a  considerable  proportion  of  each  was  depressed 
in  mind  more  or  less.  Certainly  the  tendency  to  suicide 
is  very  hereditary.  I^ext  to  heredity  come  as  causes 
disordered  bodily  functions,  and  after  them,  at  a  long  distance, 
moral  and  mental  causes  of  depression.  Domestic  affliction  is 
by  far  the  most  frequent  of  the  last  in  the  female  sex,  and 
business  anxieties  in  the  male  sex. 

Prognosis. — Out  of  the  last  1000  cases  admitted  into  Morn- 
ingside  Asylum,  54  per  cent,  have  recovered.  "Within  the 
past  seven  years,  under  1  per  cent,  have  died  of  the  direct 
exhaustion  from  the  disease  while  recent.  The  liabiHty  to 
relapse  after  recovery  is  best  represented  by  the  number  of 
previous  attacks,  which  had  existed  in  about  one-third  of  all 
the  cases.  It  must  be  remembered  that  those  statistics  refer 
to  cases  so  ill  as  to  need  asylum  treatment.  I  have  no  doubt 
that  if  the  milder  cases  treated  at  home  were  included  the 
recovery  rate  would  be  much  greater. 

The  things  that  enable  us  to  form  a  good  prognosis  are 
youth ;  sudden  onset ;  an  obvious  cause  that  is  removable  ; 
want  of  fixed  delusion ;  absence  of  prolonged  hallucinations 
of  hearing,  taste,  or  smell ;  no  visceral  delusions ;  no  strongly 
impulsive  or  epileptiform  symptoms  ;  no  picking  of  the  skin, 
or  pulling  out  the  hair,  or  such  trophic  symptoms ;  no  long- 
continued  loss  of  body  weight  in  spite  of  treatment ;  no  long- 
continued  inattention  to  the  calls  of  nature,  and  no  dirty 
habits.  Almost  never  pronounce  a  patient  incurable  while 
depression  continues. 

But  be  guarded  in  giving  a  definite  prognosis  in  almost 
every  case.     The   greater   my  experience  becomes  the   more 


124  STATES   OF  MENTAL   DEPRESSION. 

guarded  I  am.  Some  of  the  most  favouraUe-looking  cases 
will  deceive  you,  while  some  that  look  most  hopeless  will 
recover,  as  in  the  case  of  B.  S.  A.,  a  patient  of  mine,  who  had 
been  seven  years  melancholic,  suicidal,  and  sleejyless,  and  who 
recovered  at  74,  was  quite  toell,  and  did  her  household  work  for 
seven  years,  hut  then  relapsed  and  died  melancholic. 

The  bad  signs  are  a  slow  gradual  onset,  like  a  natural 
evolution;  fixed  delusions,  especially  visceral  and  organic 
delusions  j  gradual  decay  of  bodily  vigour,  like  a  premature 
old  age  ;  persietent  loss  of  nutritive  energy  and  body  weight ; 
convulsive  attacks  and  motor  affections  generally,  not  merely 
ideo-motor ;  persistent  hallucinations,  especially  of  hearing, 
smell,  and  f  eeHng ;  a  tendency  to  enf  eeblement  of  mind ; 
picking  the  skin  or  hair ;  a  growth  of  hair  on  the  face  in 
women ;  persistent  refusal  of  food ;  an  unalterable  fixity  of 
emotional  depression  of  face  or  persistence  of  muscular 
expressions  of  mental  pain  (wringing  hands,  groaning,  &c.)  ; 
persistent  suicidal  tendency  of  much  intensity ;  arterial 
degeneration ;  senile  degeneration  of  brain ;  no  natural  fatigue 
following  persistent  motor  efforts  in  walking,  standing,  &c. 

Termination  of  Melancholia. — Of  the  540  cases  that  termin- 
ated in  recovery,  50  per  cent,  recovered  within  three  months, 
75  per  cent,  under  six,  87  per  cent,  under  twelve  months, 
leaving  only  13  per  cent,  who  took  more  than  a  year  to 
recover. 

In  most  cases  recovery  is  gradual.  In  my  experience  an 
improvement  in  the  bodily  condition  and  looks,  in  the 
vascular  condition,  and  an  increase  in  the  body  weight  and 
appetite,  nearly  always  precede  the  mental  improvement. 
The  motor  restlessness  generally  passes  off  first.  The  patients 
sit  down  and  do  work  of  some  sort,  then  they  begin  to  eat 
better,  then  the  delusions  lose  their  intensity,  then  the  sense 
of  ni-being  is  less  oppressive.  There  is  often  an  irritable 
stage  as  improvement  sets  in.  I  have  one  patient  whom  I 
am  always  glad  to  hear  swearing:  I  know  then  that  he  is 
going  to  recover.     The  return  of  the  sense  of  well-being  is 


STATES   OF   MENTAL  DEPRESSION.  125 

the  last  to  come,  and  along  with  it  that  surplus  stock  of 
nervous  energy  in  all  directions  that  constitutes  Health.  A 
man  whose  nerve  capital  is  always  running  low  can  never 
be  said  to  be  in  really  good  safe  health.  When  I  see  a 
recent  case  taking  on  flesh  at  the  rate  of  three  or  four  pounds 
a  week  I  know  he  is  probably  safe,  and  will  make  a  good 
recovery.  The  only  exceptions  to  this  are  in  the  long- 
continued  cases,  where  the  mental  functions  of  the  convolu- 
tions are  permanently  enfeebled  and  damaged,  and  in  whom, 
as  the  depression  passes  off,  we  have  a  fat  dementia  resulting. 
This,  however,  is  much  more  uncommon  in  melancholia  than 
in  mania.  Some  patients — a  few — make  sudden  recoveries 
in  a  few  days.  I  have  even  seen  a  patient  go  to  bed  very 
melanchohc  and  get  up  quite  well,  saying — "  I  see  that  all 
these  fancies  were  mere  nonsense.  I  wonder  I  could  have 
been  so  foolish  as  to  believe  them."  Such  cases  describe 
their  sensation  as  being  "  a  cloud  Hfted  off  their  mind." 
But  on  the  whole  I  hke  slow  recoveries  better  than  sudden 
"  cures." 

A  few  of  the  cases  end  in  the  chronic  melancholia  I  have 
described.  They  were  nearly  all  middle-aged  or  old  people. 
Many  of  the  cases  pass  into  mania,  a  few  become  alternating 
insanity,  and  a  few  pass  into  dementia,  which,  in  that  case, 
is  never  so  complete  and  absolute  a  mental  enfeeblement  as 
when  it  follows  mania. 

Summary  of  Treatment  of  the  States  of  Mental  Depression. 
— If  the  brain  and  body  conditions  that  accompany,  if  they 
do  not  cause,  states  of  morbid  mental  depression  are  those  of 
trophic  deficiency,  as  we  have  seen  is  undoubtedly  the  case 
in  most  instances,  then  it  necessarily  follows  that  what  will 
remedy  those  conditions  is  indicated,  and  all  things  that  will 
aggravate  them  must  be  avoided.  Even  in  the  patients  where 
there  is  no  demonstrable  lack  of  brain  or  body  nourishment, 
and  where  the  disease  is  more  of  a  purely  dynamical  brain 
disturbance,  and  of  a  disordered  energising  of  the  convolu- 
tions from  hereditary  instabihty,   there  is  lack  of  force  and 


126  STATES   OF  MENTAL  DEPKE3SI0N. 

general  vitality  in  tlie  brain.  "We  make  the  conditions  of 
life  of  a  melancholic,  therefore,  as  physiological  and  favour- 
ahle  as  we  can.  Every  therapeutic  agent  whose  effect  is 
tonic,  hunger-producing,  digestive,  vaso-motor,  and  nerve- 
stimulating  we  give.  Quinine  I  place  in  the  first  rank; 
iron,  the  phosphates,  hypophosphites,  strychnine,  phos- 
phorus, &c.,  in  the  second ;  and  the  mineral  acids,  vegetable 
bitters,  aloes,  arsenic,  digitalis,  strophanthus,  gentle  laxatives, 
cholagogues,  diuretics,  and  diaphoretics  in  the  third.  Kot 
that  I  have  not  seen  quinine  and  strychnine  over-stimulate 
and  have  to  be  stopped,  and  iron  determine  blood  to  the 
brain  in  a  way  to  do  harm,  but  those  HI  effects  are  rare,  and 
they  can  be  stopped  as  soon  as  observed.  The  mineral 
waters  of  our  own  country,  and  especially  those  of  Germany, 
come  under  the  same  category  as  those  tonics.  Many  a 
commencing  melancholic  have  I  seen  cured  most  pleasantly 
by  a  short  stay  in  Schwalbach,  "Wiesbaden,  Carlsbad,  &c. 
Of  course  the  particular  kind  of  water  must  be  determined  by 
the  diathesis — the  chalybeate  to  the  neurotic,  the  sahnes  and 
the  sulphur  to  the  gouty  and  rheumatic,  &c.  The  continued 
current,  appHed  not  too  strong,  and  passed  through  the  great 
nervous  centres,  is  greatly  trusted  by  some  continental 
physicians,  and  I  have  seen  it  do  good  in  patients  with  the 
elements  of  stupor  present. 

Diet  and  regimen  are  of  the  highest  importance.  If  I  were 
as  sure  of  everything  else  in  therapeutics  as  this,  that  fresh 
air  and  fattening  diet  are  good  for  melancholic  people,  I 
should  have  saved  myself  many  medical  questionings.  Such 
patients  cannot  have  too  much  fresh  air,  though  they  may 
have  too  much  walking,  or  gymnastics,  or  muscular  fatigue. 
It  is  the  best  sleep-producer,  the  best  hunger-producer,  and 
the  best  aid  to  digestion  and  ahmentation.  "Without  it  all 
the  rest  is  totally  useless  in  most  cases.  Patients  cannot 
fatten  too  soon  or  too  fast,  though  their  stomach  and  bowels 
may  be  overloaded,  and  their  hvers  and  kidneys  may  be  too 
engorged.      Fatty   foods,  milk,  ham,    cod-hver   oil,  maltine, 


STATES  OF  MENTAL  DEPRESSION.  127 

eggs,  farinaceous  diet,  easily  digested  animal  food  such  as 
fish,  fowl,  game,  &c.,  are  my  favourite  diet  for  melancholies. 
Milk,  in  very  many  cases,  is  my  sheet  anchor.  I  have  given 
as  much  as  sixteen  tumblers  a  day  with  surprising  benefit. 
The  nervous  diathesis  does  not  put  on  fat  naturally,  there- 
fore we  must  combat  the  tendency  to  innutrition  by  scientific 
dieting.  Adipose  tissue  and  melanchoha  I  look  on  as 
antagonists ;  therefore,  when  we  want  to  conquer  the  latter 
we  must  develop  the  former.  This  is  no  new  doctrine. 
"  Make  a  melancholy  man  fat,  as  Rliasis  saith,  and  thoa  hast 
finished  the  cure."  ^  Mrs  Carlyle  once  wrote,  after  she  had 
recovered  from  a  fearful  attack  of  "  nervousness,"  with  much 
mental  depression,  "  Oh,  thank  God  for  the  precious  layer  of 
impassivity  which  that  stone-weight  of  flesh  has  put  over  my 
nerves."  I  need  hardly  say  that  the  capacity  of  digestion, 
the  peculiarities  of  digestion,  and  the  dietetic  likings,  and 
even  the  idiosyncrasies  of  our  individual  melancholies  must 
be  studied.  A  good  cook  is  an  aid  to  all  cases,  a  pleasure  to 
most,  and  a  necessity  to  some. 

Concerning  stimulants,  I  certainly  have  found  them  useful 
in  many  cases.  The  fattening  appetising  ales  and  porters 
work  wonders  on  some  lean  anorexic  melancholies.  Good 
wines  do  the  same.  Claret  and  Burgundy  are  the  cliief, 
when  suitable  to  the  circumstances  of  the  patients,  that  do 
good.  The  stronger  stimulants  and  champagne  are  only 
needed  in  the  exhausted  cases,  except,  indeed,  when  whisky 
and  water  at  bedtime  is  a  good  soporific.  Be  sure,  however, 
that  it  is  not  the  hot  water  alone  that  causes  the  sleep. 
I  have  seen  a  tumbler  of  hot  water  taken  at  bedtime  cause 
sleep  as  quickly  as  when  mixed  with  a  glass  of  whisky,  and 
have  a  better  efi'ect  altogether.  When  a  patient  has  fairly 
gained  weight,  all  alcoholic  stimulants  may  be  discontinued, 
except  as  mere  luxuries.  Change  of  air ;  mountain  or  sea 
breezes  ;  change  of  scene  ;  quiet  in  most  cases  ;  active  travel 
and  bustle  in  a  few  of  the  less  serious  cases ;  long  voyages, 
^  Burton's  Anatomy  of  Melancholy,  16th  ed.,  1836,  p.  449, 


128  STATES   OF   MENTAL   DEPEESSION. 

if  we  are  quite  sure  that  the  disease  does  not  threaten  to 
become  acute  or  suicidal, — all  these  things  are  helpful.  "VVe 
enjoin  rest  from  exhausting  or  irritating  work ;  above  all, 
escape  from  worry.  "We  bring  a  different  set  of  faculties 
and  a  different  group  of  muscles  into  action  from  those  chat 
have  been  employed  before.  Do  not  push  anything  that  is 
too  great  a  conscious  effort  for  the  patient  to  do.  Do  not 
send  a  man  to  fish  if  fishing  is  a  disagreeable  toil,  or  make 
him  go  into  "  cheerful  society  "  when  this  is  a  real  torture  to 
him.  Pleasant  society  with  no  bustle,  beautiful  scenery, 
music,  and  sunshine,  are  all  healing  to  melancholy.  In  most 
cases  some  occupation  that  is  a  pleasure  has  to  be  encouraged, 
and  does  much  good.  Fishing,  easy  mountaineering,  shooting, 
boating,  golf  and  outdoor  games,  are  most  suitable  for  certain 
cases.  We  try  and  make  the  impressions  received  by  the 
senses  agreeable,  and  therefore  harmonious  with  the  well- 
being  of  the  organism.  We  try  and  substitute  pleasurable 
feelings  for  painful  ones  by  every  means  known  to  us.  Slow 
travel,  with  a  cheery  sensible  companion,  who  is  of  course 
twice  as  valuable  if  he  is  a  doctor,  saves  many  a  man  from 
an  asylum.  In  most  cases  we  remove  a  man  temporarily 
from  his  wife  and  family,  for  paralysed  or  perverted  affection 
to  a  melancholic  is  itself  a  painful  thing  and  a  source  of 
depression.  But  there  are  marked  exceptions  to  this  rule — 
cases  where  a  man's  wife  is  the  best  nurse,  his  children  his 
best  companions.  In  bad  cases  a  cheerful  trained  attendant 
and  a  young  doctor  make  a  capital  team  for  the  melancholic 
who  needs  attention,  company,  and  medical  supervision.  We 
try  to  remove  the  patient  from  surroundings  that  are  de- 
pressing to  those  that  will  rouse  pleasant  thoughts,  and  to 
take  him  from  the  place  where  his  malady  arose.  Every- 
thing and  every  person  there  may  suggest  pain  to  him.  But 
he  must  not  always  have  his  own  way.  Quite  the  contrary. 
In  most  instances  another  will  must  overcome  his  own,  and  be 
substituted  for  it.  This  is  a  reason  why  mothers,  wives,  and 
sisters  so  often  do  harm,  because  they  let  the  patient  have  too 


STATES   OF   MENTAL   DEPRESSION.  129 

much  of  his  own  way.  It  is  certainly  well  if  those  alDOut 
him  have  physiologically  a  surplus  stock  of  animal  spirits  to 
infuse  into  him.  Much  tact  is  needed  in  personal  intercourse 
with  melancholies,  as,  indeed,  with  all  the  insane.  Seldom 
argue  with  them  or  contradict  their  delusions.  Do  not  agree 
with  them,  but  change  the  subject.  Discourage  introspection, 
encourage  observation  of  and  talk  about  things  without 
them.  Don't  let  the  hypnotists  only  take  advantage  of  the 
powerful  aid  of  "suggestion";  never  cease  to  assure  them 
they  will  get  well  and  are  getting  well.  In  a  few  cases  the 
use  of  hypnotism  by  Dr  Eobertson  here  has  overcome  per- 
sistent sleeplessness,  and  "hypnotic  suggestion"  has  intro- 
duced cheerful  ideas.  Every  neurotic  man  should  have  an 
outdoor  hobby.  That  would  save  many  of  them  from 
melancholia. 

Suicide. — Guard  against  suicide,  and  make  the  friends  and 
attendants  feel  that  there  is  a  real  risk  of  its  being  com- 
mitted. They  get  into  the  state  of  mind  of  railway  porters, 
who  are  so  accustomed  to  risks  that  they  forget  all  about 
them.  I  have  seen  suicidal  melancholies  by  the  dozen,  about 
whom  I  had  given  warnings  as  strong  as  I  could  make  them, 
that  every  article  by  which  suicide  might  be  effected  should 
be  removed,  and  yet  found  knives  in  their  pockets,  and 
razors  in  their  dressing-cases.  The  bad  cases  should  never  be 
left  alone.  I  once  had  a  suicidal  patient  under  the  charge  of 
an  attendant,  who  was  said  to  be  experienced,  and  I  found 
my  patient  in  a  top-story  room  alone,  with  a  loaded  revolver 
in  his  pocket  and  a  razor-case  in  his  room,  and  yet  his  mother 
and  his  attendant  did  not  seem  to  see  how  great  the  risk 
had  been. 

Why  an  Asylum  does  good. — Many  melancholies  are  intensely 
selfish,  tliink  of  nobody  but  themselves,  bore  their  friends 
with  recitals  of  their  own  feelings,  and  crave  sympathy  with 
a  morbid  intensity.  Too  much  expressed  sympathy  in  most 
cases  feeds  the  disease.  To  distract  the  attention  from  morbid 
thoughts  and  feelings  by  any  means  should  be  the  one  great 


130  STATES  OF   MENTAL   DEPRESSION. 

'aim  in  personal  intercourse.  Strangers  often  do  better  with 
melancholies  than  friends.  Many  of  them  take  most  strong 
and  unfounded  morbid  dislikes.  They  exercise  more  self- 
control  before  strangers,  and  the  strengthening  of  the  power 
of  self-control  is  half  the  cure.  That  is  why  removal  to  an 
asylum  is  sometimes  followed  by  immense  benefit.  A  patient 
who  at  home  has  been  groaning,  noisy,  idle,  and  unmanage- 
able, finds  himself  among  strangers,  subjected  to  rules  and 
disciphne  and  ordinary  living,  and  has  objects  of  fresh  interest 
presented  to  him,  and  he  becomes  a  different  man  at  once. 
I  asked  a  man  who  had  been  very  ill  and  unmanageable  at 
home,  and  who  seemed  to  come  round  in  a  few  days  in  the 
Asylum,  what  had  cured  him.  His  reply  was — "I  found 
myself  among  a  lot  of  people  who  did  not  care  a  farthing 
whether  I  was  miserable  or  not,  which  made  me  angry,  and 
I  got  well."  Being  by  far  the  most  conscious  form  of  insanity, 
it  would  seem  the  hardest  on  the  patients  to  send  them  to  an 
asylum,  but,  in  reality,  removal  to  an  asylum  does  more  good 
to  certain  melanchoHcs  than  to  any  other  class  of  the  insane. 
What  is  good  is  not  always  pleasant  in  moral  as  well  as  in 
medical  treatment.  There  is  no  use  dunning  a  patient  to 
"rouse  yourself,"  to  "throw  off  your  dulness,"  to  "drop 
those  fancies,"  for  in  many  cases  it  would  just  be  as  wise  to 
tell  a  hemiplegic  to  "  move  that  leg." 

As  regards  sending  a  patient  to  an  asylum,  and  when  to  do 
it,  no  rules  can  be  laid  down.  Among  the  poor  it  must  be 
done  in  most  bad  cases,  and  soon  ;  though  nowadays  a  work- 
ing man  can  get  a  complete  change  of  air  and  scenery  for  a 
shilhng.  Among  the  very  rich  few  melanchohcs  are  sent  to 
asylums  till  their  relations  are  tired  out  with  them  or  they 
become  very  suicidal.  No  doubt  the  risks  of  suicide  are 
much  less  in  an  asylum.  There  is  disciphne,  order,  a  hfe 
under  medical  rule,  suitable  work,  much  amusement,  and  the 
means  of  carrying  out  what  is  good  for  the  patient.  "VYhen 
from  any  cause  you  cannot  get  the  treatment  carried  out  that 
you  know  is  necessary  for  the    patient,  then  an  asylum  is 


STATES  OF   MENTAL   DEPKESSION.  131 

needful.  When  the  symptoms  persist  too  long  without 
showing  signs  of  yielding,  when  the  risk  of  suicide  is  very 
great,  when  the  patient  has  foolish  friends  who  will  not  carry 
out  any  rational  plan  of  treatment,  or  when  he  gets  too  much 
sympathy  or  none  at  all — in  all  these  cases  an  asylum  is 
indicated.  Many  patients  who  resist  all  right  treatment  at 
home  will  submit  to  it  at  once  in  an  asylum. 

Nursing. — Good  nursing  in  the  weak  cases,  just  as  you 
would  nurse  a  fever  patient,  is  of  the  last  importance.  A 
nurse  that  will  insist  and  persist  till  the  insane  opposition 
and  the  repugnance  to  food  is  overcome,  is  what  we  want.  It 
is  very  easy  to  let  a  melancholic  slowly  starve  himself,  while 
he  yet  takes  some  food  at  every  meal. 

Baths  are  most  useful,  especially  Turkish  baths.  I  have 
seen  many  chronic  incurable  melanchoHcs  much  improved  and 
some  cured  by  a  course  of  Turkish  baths.  The  wet  pack  is 
often  useful. 

Hypnotics  and  Sedatives. — Some  of  our  greatest  difficulties  in 
treating  a  case  of  melancholia  are  whether  to  give  narcotics  and 
sedatives,  when  to  give  them,  what  to  give,  and  when  to  stop 
them.  Opium  I  greatly  disbelieve  in.  I  performed  a  series 
of  elaborate  experiments  with  it  in  melanchoha,^  and  it  always 
caused  a  loss  of  appetite  and  loss  of  weight  in  every  case,  and 
Dr  Mickle  has  confirmed  these  results.^  I  have  seen  very 
few  melancholies  in  whom  I  was  sure  opium  did  good.  Chloral 
is  very  useful  as  a  temporary  expedient  to  get  sleep.  I  now 
always  give  small  doses — never  more  than  25  grains,  generally 
keeping  to  15,  combined  with  from  20  to  50  grains  of  the  bro- 
mides of  potassium,  sodium,  or  ammonium.  But  I  now  seldom 
give  chloral  long.  I  am  satisfied  that  one  effect  of  its  prolonged 
use  is  to  reduce  the  tone  of  the  nervous  system,  and  to  lessen 
the  power  of  enduring  pain,  mental  or  bodily.  I  very  often 
use  paraldehyde  in  doses  beginning  with  40  minims  and  going 
up  to  4  drachms,  with  great  confidence  that  its  sleep  is  a 

^  "  Fothergillian  Prize  Essay  for  1870,"  Brit,  and  Foreign  Med.-Ch.ir. 
Review,  October  1870  and  Jauuary  1871.         ^  Practitioner,  June  1881. 


132  STATES   OF  MENTAL  DEPRESSION. 

more  natural  one  tlian  any  other  hypnotic  known  to  me. 
I  have  lately  had  several  cases  where  the  pabients  gained  in 
weight  and  improved  in  mind  steadily,  while  getting  some 
sleep,  by  taking  a  drachm  of  paraldehyde  every  night,  while 
they  at  once  fell  off  when  this  was  discontinued.  They  all 
made  good  recoveries.  Fifteen  or  20  grains  of  the  bromides 
added  to  the  paraldehyde  will  sometimes  prolong  the  sleep. 
Sulphonal,  in  doses  of  from  20  to  30  grains,  is  a  most  valuable 
drug,  because  it  acts  as  a  hypnotic  and  motor  sedative  com- 
bined, its  effects  are  prolonged  and  its  after-effects  are 
seldom  bad.  In  some  of  the  excited  cases  it  is  invaluable. 
Hyoscine,  in  doses  beginning  with  -^^  grain  hypodermically 
and  going  to  ^  of  a  grain,  is  often  very  sedative  in  the 
excited  cases.  We  combine  tonics  and  sedatives  very  often. 
Lately  I  prescribed  for  a  very  intractable  case  of  agitated 
melanchoHa  with  hallucinations,  overpowering  "suggestions" 
from  her  sexual  organs,  and  deep  misery — altogether  a  bad 
case  of  over  a  year's  duration — a  mixture  of  bromide  of  soda, 
arsenic,  and  iron  with  the  most  astonishing  and  immediate 
benefit.  The  bromides  when  long  given  are  depressing. 
Tincture  of  henbane,  in  doses  from  1  drachm  to  4,  is  very 
useful  as  a  temporary  expedient  in  the  very  agitated  cases, 
and  so  is  conium ;  but,  of  all  the  day  sedatives,  I  have  found 
a  mixture  of  Tinct.  Cannabis  Indicse  (from  x.  min.)  and 
bromide  of  potassium  (from  xx.  grs.)  or  sulphonal  do  the 
most  good  and  the  least  harm  to  the  appetite  for  food.  We 
have  not  yet  discovered  a  perfect  narcotic  that  gives  brain 
quiet  combined  with  increased  appetite  and  body  weight, 
Tinct.  Lupuli  I  have  found  of  much  service  in  some  mild 
cases,  and  it  did  no  harm  whatever  ;  and  of  chloralamide  and 
urethane  I  would  say  the  same. 

I  have  seen  many  cases  cured  by  a  crop  of  boils,  a  carbuncle, 
or  an  attack  of  erysipelas,  and  in  one  case  by  an  attack  of 
dysenteric  diarrhoea,  I  think  we  shall  some  day  be  able  to 
inoculate  a  septic  poison,  and  get  a  safe  manageable  counter- 
irritant  and  fever,  and  so  get  the  "  alterative  "  effect  of  such 


STATES   OF   MENTAL   DEPKESSION.  133 

things,  and  the  reaction  and  the  stimulus  to  nutrition  that 
follow  febrile  attacks.  A  new  method  of  doing  this  has  lately 
been  devised  by  Dr  Lewis  C,  Bruce,  now  one  of  the  assistant 
physicians  here,  which  is  sometimes  followed  by  astonishingly 
good  results.  He  uses  thyroid  extract  in  doses  of  60  grains  a 
day,  putting  the  patient  through  a  course  of  tliis,  lasting  for 
from  four  to  nine  days  in  different  cases.  The  patients  must 
be  put  to  bed  during  the  treatment,  and  kept  there  for  some 
days  afterwards,  for  they  become  feverish,  the  temperature 
rising  to  99°  or  101°  in  different  cases,  the  heart's  action 
becoming  lowered,  and  the  patient  rapidly  losing  flesh.  The 
extract  clearly  acts  as  a  direct  cortical  stimulant,  as  well  as  an 
excitant  of  fever  and  an  alterative,  for  I  have  seen  patients 
change  from  a  melancholic  to  a  maniacal  condition  during  its 
use.  After  the  extract  is  discontinued  the  appetite  usually 
becomes  ravenous.  The  weight  runs  up  from  half  a  stone 
to  three  stones,  and  a  surprising  mental  improvement,  ending 
in  recovery  in  some  cases,  takes  place.  It  should  be  used 
in  every  case  that  threatens  to  become  chronic. 

Prophylaxis  in  Melanclwlia. — I  tliink  our  profession  could 
diminish  the  amount  of  melancholia  if  they  were  consulted 
sooner  and  more  often  as  to  the  prophylaxis  in  patients  who 
have  had,  are  threatened  with,  or  who  are  predisposed  to, 
states  of  mental  depression.  Especially  is  the  preventive 
aspect  most  important  in  the  dieting,  regimen,  education,  and 
work  of  the  children  of  this  class.  If  we  could  make  all  these 
measures  counteractive  of  the  temperament  and  heredity, 
instead  of  accentuating  them  unduly,  we  could  do  much  good, 
and  prevent  an  enormous  amount  of  unhappiness  in  the  world. 
It  is  surprising  how  soon  such  children  show  their  brain 
instability.  A  "too  sensitive"  child  should  always  be  looked 
after.  Children  of  this  class  take  "  crying  fits"  and  miserable 
periods  on  slight  or  no  provocation.  We  do  not  caU  these 
things  melancholia,  but  depend  upon  it  they  often  have  a 
close  kinship  to  it.  Such  children  should  be  kept  fat  from 
the   beginning;  they  should  get  little  flesh  diet,  and  much 


134  STATES   OF  MENTAL  DEPRESSION. 

milk  till  after  puberty.  Their  brains  should  not  be  forced 
in  any  way.  They  should  be  much  in  the  fresh  air.  They 
should  not  read  much  imaginative  literature  too  soon.  They 
should  be  brought  up  teetotalers  and  non-smokers.  They 
should  sleep  much.  Public  school  life  is  often  most  detri- 
mental to  them.  If  they  are  bullied  they  suffer  frightfully. 
(Eead  poor  Cowper  and  Lamb's  lives.)  If  they  are  taught 
masturbation  it  takes  a  frightful  hold  of  them,  and  it  is  they 
who  are  ruined  by  it  in  body,  mind,  and  morals.  The  modern 
system  of  cramming  and  competitive  examinations  is  one  of 
the  most  potent  devices  of  the  evil  one  yet  found  out  for 
the  destruction  of  their  chances  of  happiness  in  life.  Such 
children  are  often  over-sensitive,  over-imaginative,  and  too 
fearful  to  be  physiologically  truthful,  and  tend  under  fostering 
to  be  unhealthily  religious,  precociously  intellectual,  sensuously 
artistic,  and  at  first  hypersesthetically  conscientious.  !N"ow,  a 
wise  physician  will  fight  against  the  average  schoolmaster  in 
all  these  things.  Such  children  should  be  taught  to  systema- 
tise their  time  and  their  lives,  to  develop  their  fat  and  muscle, 
and  to  lead  calm  lives  of  regular  orderly  occupation. 

As  regards  the  prophylaxis  in  those  who  have  already 
suffered  from  melancholia,  at  the  risk  of  being  thought  to  ride 
a  hobby,  I  tell  such  persons,  one  and  all,  to  keep  fat,  and 
keep  their  brains  quiet.  Let  them  take  precautions  in  time. 
The  falling  off  of  a  few  pounds  in  weight  may  be  to  them  the 
first  real  symptom  of  the  disease  returning,  even  though  they 
feel  at  the  time  as  well  and  hearty  as  possible.  It  is  at  this 
stage  that  change  and  rest  do  most  good.  I  always  advise 
my  recovered  melancholic  patients  to  weigh  themselves 
regularly,  and  keep  a  record  of  their  weight,  to  lead  a  regular 
life,  and  to  practise  system  and  order  in  their  work.  Reducing 
their  ordinary  lives  to  a  routine  is  the  safest  thing  for  them 
if  they  can  do  it.  Like  leanness,  want  of  system  and  method 
goes  with  a  tendency  to  melancholia,  in  my  experience. 
They  should  not  work,  or  think,  or  feel  in  big  spurts.  And 
as  the  great  epochs  and  crises  of  life — pregnancy,  childbirth, 


STATES  OF  MENTAL   DEPKESSION.  135 

the  climacteric,  and  senility — approach,  let  special  care  he 
taken  hy  them.  Do  not  let  them  get  to  depend  on  soporifics 
for  sleep.  ^Nothing  is  more  dangerous.  An  hour's  natural 
sleep — "tired  nature's  sweet  restorer" — may  be  worth  eight 
hours'  drug-sleep.  A  country  life,  with  much  fresh  air,  is  no 
doubt  the  best  in  most  cases,  if  it  is  possible.  Regular  changes 
of  scene,  "breaks"  in  occupation,  and  long  holidays,  are  of 
course  most  desirable  for  such  people.  Though  travel  and 
change  are  very  often  harmful  to  actual  melancholic  patients, 
yet  to  many  persons,  who  merely  have  the  temperament  and 
the  tendency,  they  are  most  effective  in  warding  off  attacks. 
I  know  several  people  who  in  that  way  seem  to  keep  well 
and  moderately  happy.  The  great  thing  to  be  avoided  is  too 
fatiguing  travel — seeing  too  much  in  too  short  a  time. 


LECTURE    IV. 

STATES  OF  MEXTAL  EXALTATION— MANIA 
{PSYGHLAMPSIA). 

Physiological  exaltation — Sanguine  variety  of  neurotic  temperament; 
"excitability"  of  disposition — Mental  exaltation  physiological  in 
childhood ;  delirious  exaltation  easily  excited  by  increased  tempera- 
ture in  childhood — Exaltation  and  delirium  occur  at  beginning  and 
acme  of  febrile  disorders ;  depression  at  end  and  afterwards — Sane 
V.  Insane  exaltation — Exaltation  of  function  follows  increased 
circulation,  oxygenation,  and  heat  in  brain — Mania  defined  objec- 
tively, Melancholia  subjectively.  Characters.  —  First  Stage  : 
Sleeplessness  ;  unsettleduess  ;  talkativeness  ;  constant  muscular 
action  ;  changeability  ;  irritability ;  diminished  self-control ;  extra- 
vagance ;  loss  of  the  sense  of  the  proprieties,  fitnesses,  and  conven- 
tional moralities  ;  change  in  the  natural  affections  and  habits  ; 
"  common  sense  "  gone  ;  increase  in  imaginative  power  and  amount 
of  mentalisation  ;  "whole  man"  different;  loss  of  bod)''  weiglit ; 
denial  that  anything  is  wrong — Secoml  Stage :  Total  loss  of  self- 
control  ;  incoherence  ;  violence  ;  destructiveness  ;  filthy  habits  ; 
taste,  smell,  and  common  sensibility  perverted  ;  shouting  ;  roaring ; 
facial  expression  totallj^  altered  ;  rapid  loss  of  weight,  and  exhaustion 
of  strength;  tongue  and  mouth  dry;  secretions  altered,  and  men- 
struation stopped — The  association  of  ideas  in  incoherence  ;  pre- 
sentation and  representation — Differential  Diagnosis :  From  alcohol ; 
poisons  ;  "suppressed"  and  "masked"  fevers  and  inflammations  ; 
injuries  to  head  ;  excited  melancholia — Prognosis :  54  per  cent, 
recover  from  mania  (Royal  Edinburgh  Asylum).  Varieties. — 1. 
Simple  Mania  :  Fii'st  stage  of  ordinary  mania  or  distinct  condition 
— Treatment :  Largely  preventive  and  regulative,  giving  outlets  for 
morbid  brain  energy — Prognosis:  Good.  2.  Acute  Mania:  Onset 
sudden  or  gradual ;  forms  8  per  cent,  of  admissions  to  Royal  Edinburgh 
Asylum ;  not  so  common  or  typical  as  of  old — Characters :  Within  six 
weeks  duration — sleeplessness  ;  appetite  gone  or  perverted  ;  mus- 
cular movements  constant  and  purposeless  ;  gesticulation;  violence  ; 
unman  ageability;  unconsciousness;  delirium  ;  total  incoherence;  loss 


STATES  OF  MENTAL  EXALTATION.  137 

or  perversion  of  memory,  presentation,  representation,  and  attention  ; 
expression  of  eyes  and  face  ;  high  temperature  increased  at  night ; 
functions  of  skin,  bowels,  and  digestion  disordered — Delirious 
Mania — Treatment :  Food  ;  stimulants  ;  open  air  ;  sedatives  ; 
skilled  attendance  ;  general  management  ;  safety  ;  anything  that 
impairs  appetite  or  digestion  bad  ;  give  muscular  outlet  to  cortical 
storm — Prognosis:  60  per  cent,  recover,  74  per  cent,  die,  and  32^ 
per  cent,  become  demented,  or  pass  into  chronic  mania  or  mono- 
mania. 3.  Delusional  Mania :  Delusion  the  essential  element, 
usually  fixed,  with  excitement — Prognosis  :  Not  good  ;  greatly 
depends  on  fixity  and  intensity  of  delusion.  4.  Chrmiic  Mania  : 
Acute  mania  continued  in  a  modified  way  over  a  year,  with  the 
usual  elements  of  dementia — Treatment :  A  lunatic  asylum — Prog- 
nosis:  Bad — Preventive  and  hygienic  treatment  of  tendency  to 
morbid  exaltation — "  Cutting  short "  an  attack.  5.  Mania  Tran- 
sitoria  (Ephemeral  Mania)  :  A  rare  form  ;  coming  on  suddenly,  and 
lasting  a  few  hours  ;  commonly  a  "  mental  epilepsy,"  or  a  "  masked 
epilepsy."  It  means  great  instability  of  mental  cortex.  6.  Homi- 
cidal Mania :  Maniacal  excitement,  which  chiefly  takes  the  form  of 
desire  and  attempts  to  take  away  life — Prevalence  of  Mania  :  It  is 
one-half  more  common  in  Asylums  (not  in  general  practice)  than 
melancholia,  and  it  occurs  at  earlier  ages. 

Like  conditions  of  mental  depression,  states  of  mental  exalta- 
tion, up  to  a  certain  degree,  may  be  normal  and  physiological. 
This  is  especially  apt  to  be  the  case  in  persons  combining 
the  sanguine  temperament  and  the  nervous  diathesis.  Every 
one  has  met  with  the  sort  of  person  of  high  spirits  who  is 
easily  elated,  has  little  power  of  controlling  the  outward 
manifestations  of  exalted  emotion,  is  quite  carried  away  by 
joyous  news  or  pleasurable  feeling,  so  that  he  talks  loud  and 
fast,  cannot  sleep,  cannot  rest,  acts  in  strange  excited  ways, 
and  perhaps  dances  and  sings — all  without  cause  that  appears 
sufficient  to  produce  these  effects.  Such  conduct  may  be 
perfectly  natural  and  physiological  in  any  man,  if  the  cause 
be  sufficient;  but,  in  the  Teutonic  races,  at  all  events,  such 
causes  do  not  occur  very  often  in  the  adult  lifetime  of  an 
ordinary  man.  If  such  mental  exaltation  does  occur  in  any 
one  on  quite  insufficient  cause,  or  if  it  continues  to  manifest 
itself  long  after  the  cause  has  operated,  we  say  that  such 
a   person   is   of   a   very    "  excitable    temperament."      Many 


138  STATES  OF.  MENTAL  EXALTATION. 

bodily  diseases  in  persons  of  this  constitution  are  apt  to  be 
accompanied,  and  are  often  much  complicated,  by  such  brain 
excitement. 

Mental  exaltation  is  perfectly  natural  in  childhood.  It  is, 
in  fact,  the  physiological  state  of  brain  at  that  period.  Hence, 
whenever  the  temperature  of  the  brain  rises,  from  febrile 
disorders,  in  children,  we  are  apt  to  have  delirious  mental 
exaltation,  I  found  on  investigation  at  the  Sick  Children's 
Hospital  here,  that  by  far  the  majority  of  the  cases  of 
delirium  in  the  young  patients  there  are  chaTacterised  by 
pleased  or  exalted  feeling,  and  by  pleasant  hallucinations,  the 
few  exceptions  being  usually  severe  burns  or  such  very  pain- 
ful affections.  But  if  a  grown  man  exhibited  the  same 
symptoms  of  mental  exaltation  as  are  normal  in  a  child  it 
would  be  accounted  morbid,  and  he  would  be  reckoned  in- 
sane. In  children  of  neurotic  constitution  this  is  apt  to 
become  a  most  serious  complication.  While  a  high  tempera- 
ture is  apt  to  cause  violent  delirium  in  such  children,  it  is  in 
them,  too,  that  reflex  peripheral  irritations,  such  as  teething, 
rickets,  worms,  undigested  or  indigestible  food  in  the  stomach, 
cause  convulsions.  The  delirious  and  the  eclampsic  point  of 
different  children  is  a  field  weU  worthy  of  attention,  and  a 
knowledge  of  it  might  be  most  useful  in  their  after  life- 
history  and  disease-history.  In  adults  of  this  constitution  a 
febrile  catarrh,  a  mild  attack  of  rheumatism,  or  gout,  or 
inflammation  may  be  very  serious  matters,  from  the  sleepless- 
ness, nervous  excitement,  intensity  of  the  pain,  or  the  delirium 
present.  All  febrile  affections  act  as  a  match  to  gunpowder 
in  such  a  brain.  The  exaltation  and  delirium  are  usually 
contemporaneous  with  the  beginning  and  acme  of  febrile 
attacks,  while  depression  of  mind  follows  the  disease.  I 
consider  that  the  bodily  temperature  at  which  delirium  begins 
in  a  child  is  a  good  index  of  its  brain  constitution  and 
temperament.  I  have  known  a  very  nervous  child  always 
delirious  at  night  if  its  temperature  rose  to  99°,  while  in  most 
children   this   does   not   take  place   till   it   is  102°  or  over. 


SfATlS   OF   MENTAL  EXALTATION.  139 

Apart  from  increased  temperature,  such  children  are  subject 
to  gusts  of  unreasoning  elevation,  during  which  they  are  quite 
beside  themselves,  rushing  about  wildly,  shouting,  fighting, 
and  breaking  things,  not  really  knowing  what  they  are  about, 
this  coming  at  intervals  like  the  "attacks"  of  a  disease. 
Most  sorts  of  blood-poisons,  many  drugs,  such  as  opium, 
henbane,  Indian  hemp,  and  alcohol,  as  well  as  an  increase  of 
body  temperature,  readily  cause  maniacal  exaltation  in  the- 
brains  of  which  I  am  speaking;  and  I  have  seen  such  usually 
temporary  exaltation  not  pass  oif,  but  become  a  prolonged 
attack  of  mania  in  several  patients — one  after  a  dose  of 
cannabis  indica,  another  after  opium,  and  very  many  after 
alcohol.  All  those  were  strongly  predisposed  to  insanity  by 
heredity.  I  believe  that  convulsions,  night  terrors,  and 
"hysterical"  affections  are,  in  children  of  neurotic  heredity, 
the  equivalents  of  maniacal  attacks  at  adolescence  and  after 
in  the  same  kinds  of  brain ;  while  chorea,  somnambulism, 
asthma,  and  epilepsy  are  the  special  cerebral  neuroses  of 
puberty  and  early  adolescence  in  similar  cases.^ 

Sane  and  Insane  Exaltation. — There  is  much  less  difficulty 
in  drawing  the  line  in  most  cases  between  sane,  or  even 
between  delirious  exaltation  and  pathological  insane  exalta- 
tion, than  between  the  conditions  of  sane  and  insane  de- 
pression of  mind,  though  many  individual  cases  of  difficulty 
are  met  with.  The  reasoning  power — that  of  jxidging  rightly 
arid  comparing — is  affected  sooner  and  more  decidedly  in 
mania,  and  the  loss  of  control  in  action,  conduct,  and  muscular 
movements  is  also  sooner  seen.  That  stage  of  loss  of  memory 
and  consciousness  where  the  personality  is  lost,  and  the 
former  mental  life  and  experiences  have  disappeared,  where, 
in  fact,  the  metaphysical  ego  has  fled,  and  a  false  conscious- 
ness— an  unreal  ego — has  taken  its  place,  is  far  sooner  reached 
in  mania  than  in  melancholia.  Bevan  Lewis ^  has  "little 
doubt  that  the  process  of  reduction  is  the  same  for  both  {i.e., 
melancholia  and  mania),  but  in  maniacal  states  the  dissolution 
^  Tlie  Neuroses  of  Development,  by  the  Author.         ^  Op.  cii.,  p.  193. 


140  STATES   OF   MENTAL   EXALTATION. 

is  to  a  greater  depth;  the  difference  is  one  of  degree."  I  do 
not  agree  with  this  hypothesis.  It  seems  to  me  that  a  con- 
dition wliich  causes  pain  must  result  from  a  different  kind 
and  not  merely  a  different  degree  of  cortical  action  from  that 
which  causes  an  exaggerated  sense  of  well-being. 

The  name  "  mania  "  is  apt  to  be  used  both  professionally 
and  popularly  in  a  loose  way,  as  synonymous  with  insanity,  or 
even  to  indicate  a  mental  craze  or  eccentricity  that  falls  short 
of  that.  N'othing  is  more  common  than  to  see  in  medical 
papers  "suicidal  mania,"  when  "suicidal  melanchoha "  was 
meant.  It  is  necessary,  therefore,  to  define  the  term.  Mania 
might  be  defined  as  "morbid  mental  exaltation  or  delirium, 
usually  accompanied  by  insane  delusions,  always  by  a  com- 
plete change  in  the  habits  and  modes  of  life,  mental  and 
bodily,  by  a  loss  of  the  power  of  self-control,  sometimes  by 
unconsciousness,  and  loss  of  memory  of  past  events,  and 
almost  always  by  outward  muscular  excitement,  aU  those 
symptoms  showing  a  diseased  activity  of  the  brain  convolu- 
tions." We  think  of  melanchoha  chiefly  from  the  patient's 
subjective  point  of  view,  taking  his  affective  change  and  his 
conscious  mental  pain  chiefly  into  consideration,  while  we 
think  of  mania  more  from  our  own  objective  point  of  view, 
and  picture  the  patient's  talkativeness,  his  restlessness,  and 
his  manifest  changes  of  personaHty  and  habits :  just  as  in 
neuralgia  we  think  of  the  patient's  sensations,  and  in  tetanus 
of  the  convulsions  which  we  see  for  ourselves.  The  definition 
of  mental  exaltation,  too,  must  not  be  taken  as  if  it  were  the 
mere  opposite  of  depression  or  of  mental  pain.  I  would, 
therefore,  describe  insane  mental  exaltation  as  being  a 
morbidly  increased  and  irregular  production  of  mental  acts  by 
the  brain  with  or  without  an  increased  sense  of  well-being  or 
pleasure,  but  distinctly  without  a  conscious  sense  of  ill-being 
or  mental  pain.     Dr  G.  M.  Robertson  has  pointed  ^  out  that 

1  Journal  of  Mental  Science,  July  1890,  "Does  Mania  include  Two 
Distinct  Varieties  of  Insanity,  and  should  it  be  Subdivided,"  by  G.  M. 
Robertson,  M.B. 


STATES     OF   MENTAL   EXALTATION.  141 

in  different  cases  of  mania,  the  emotional  conditions  are  of 
two  kinds,  joy  and  rage.  The  word  excitement,  used  medico- 
psychologically,  refers  always  to  outward  visible  muscular  acts, 
such  as  restlessness,  muscular  resistance,  acts  of  violence, 
shouting,  facial  contortion,  or  movements  or  expressions  of 
the  eyes,  or  to  an  intense  desire  towards  such  acts  only 
restrained  by  a  strong  exercise  of  self-control,  when  we  use 
the  term  "suppressed  excitement." 

Most  melancholic  patients  can  tell  us  how  they  feel.  They 
know  there  is  something  wrong  with  them,  even  exaggerating 
their  mental  pain ;  while  in  most  cases  of  mania  the  patients 
affirm  they  are  quite  well,  probably  that  they  are  better  than 
they  ever  were  in  their  hves,  and  we  have  to  judge  of  their 
mental  condition  from  their  speech  and  actions,  which  become 
to  us  the  symptoms  of  the  disease. 

Varieties. — If  we  look  at  a  number  of  patients  who  are 
classified  as  labouring  under  mania,  we  see  at  once  that  there 
is  a  very  great  difference  indeed  between  diff'erent  cases. 
Without  going  into  pathology  or  causation  at  all,  the  outward 
manifestations  show  not  only  far  greater  intensity  of  morbid 
action  in  different  instances,  as  is  the  case  in  all  diseases, 
but  a  certain  difference  of  kind  of  symptoms,  mental  and 
bodily,  which  I  shall  endeavour  to  assort  for  clinical  and 
practical  purposes  into  varieties  of  the  disease ;  it  being 
understood  that  these  varieties  are  not  necessarily  distinct 
diseases  or  pathological  conditions,  but  merely  groups  of 
similar  symptoms  that  may  be  combined  with  other  groups, 
or  may  be  different  stages  in  the  same  disease.  The  great 
advantages  of  classifying  mania  into  those  varieties  are,  that 
thereby  a  student  is  less  confused  in  seeing  patients  so  very 
different  from  each  other,  and  more  especially  in  the  guide 
that  is  thus  obtained  in  treating  and  managing  patients.  The 
varieties  I  propose  to  describe  and  illustrate  by  clinical  cases 
are  : — 


142  STATES  OF  MENTAL  EXALTATION. 

a.  Simple  mania. 

b.  Acute  mania. 

c.  Delusional  mania. 

d.  Chronic  mania. 

e.  Ephemeral  mania  {mania  transitoHa). 

f.  Homicidal  mania. 

Simple  Mania. — When  a  man  of  common  sense,  who  has 
been  of  the  ordinary  type  as  to  conduct,  demeanour,  and 
speech,  undergoes,  without  sufficient  outward  cause,  such  an 
intellectual  change  that  he  becomes  loquacious,  talking  con- 
stantly to  every  one  who  will  Hsten  to  him  about  anytliing 
under  the  sun,  especially  his  own  private  affairs — when  his 
judgment  is  manifestly  not  to  be  depended  upon,  and  liis 
views  as  to  himself,  his  prospects,  his  capacities,  mental  and 
bodily,  and  his  possessions  manifestly  exceed  what  the  facts 
■warrant — -when  he  becomes  fickle,  restless,  unconventional  in 
his  conduct,  and  foohsh  in  his  manner — when  he  acts  without 
motive  and  Avithout  aim. — when,  in  fact,  his  common  sense 
has  gone,  and  his  power  of  self-control  has  become  manifestly 
lessened,  and  when  this  lasts  for  days  or  weeks,  we  say  he 
labours  under  simple  mania.  This  condition  would  seem  at 
first  sight  an  easy  one  to  describe.  But  it  is  not  so ;  for 
though  it  seems  simple,  yet,  when  we  come  to  analyse  the 
mental  faculties  involved,  and  how  they  are  affected  in 
different  cases,  we  find  an  immense  variety  of  combinations. 
IS"©  one  case  is  quite  like  another  any  more  than  any  one 
man's  mental  development  is  like  that  of  another.  A  con- 
dition of  morbid  mental  exaltation  may  exist,  and  I  beheve 
does  occur,  among  persons  of  a  nervous  heredity  far  more 
frequently  than  is  commonly  supposed,  in  shght  forms,  that 
are  not  considered  insanity  at  all.  I  would  go  the  length 
of  placing  the  "lively  moods"  to  which  some  people  are 
subject  in  the  category  of  a  direct  kinship  to  simple  mania, 
just  as  I  would  place  the  "  dull  moods "  of  some  people 
among  the  relationships  of  simple  melanchoHa.  The  longer 
I  hve  the  more  I  am  impressed  with  the  fact  that  some  of 


STATES   OF  MENTAL  EXALTATION.  143 

the  important  acts  in  the  hves  of  certain  persons  are  the 
result  of  brain  conditions  that  cannot  be  reckoned  as  being 
quite  normal.  The  men  whom  one  knows  as  subject  to 
■restless,  energetic,  boisterous  fits  lasting  for  weeks,  who 
do  cliildish,  extravagant,  or  foolish  things  at  these  times, 
whose  natural  peculiarities  are  then  much  exaggerated,  and 
whose  common  sense  seems  to  ebb  and  flow  in  an  unaccount- 
able way,  are  of  this  class.  If  we  inquire  into  the  family 
history  of  those  persons  we  are  almost  sure  to  find  a  nervous 
strain.  We  will  usually  find,  too,  that  the  more  we  take 
to  studying  the  practical  psychology  of  our  fellow-men  from 
the  point  of  vieAv  of  heredity  and  brain  function,  the  more 
will  those  pecuharities  impress  us  as  being  the  same  in  nature, 
but  less  in  degree,  than  those  greater  mental  pecuharities 
that  we  call  insanity.  Not  that  for  a  moment  I  want  to 
lessen  the  moral  responsibihty  of  such  persons  to  society  or 
the  law,  or  to  confuse  the  great  assumption  that  underlies 
all  social  arrangements  and  all  law,  that  all  men  are  sane 
and  responsible  until  proved  by  good  evidence  not  to  be  so. 
StUl  the  field  I  am  indicating  is  a  most  interesting  one  in 
the  study  of  human  nature.  I  have  known  great  fortunes  lost 
and  even  made,  great  enterprises  undertaken,  great  speeches 
made,  great  reputations  impaired,  unsulHed  characters  stained 
irretrievably  in  the  pubhc  eye,  ancient  famihes  degraded, 
marriages  contracted,  adulteries  committed,  and  unnatural 
crimes  perpetrated  by  men  and  women  whom  I  considered 
to  be  labouring  under  mild  attacks  of  simple  mania,  but 
whom  the  world  in  general  simply  looked  on  from  the 
ethical  and  legal  point  of  view.  Those  persons  were  the 
victims  of  "the  tyranny  of  their  organisation";  yet  our 
medico-psychological  knowledge  wiU  have  to  be  far  more 
accurate  and  more  widely  diffused  before  we  can  save  them 
from  it  or  its  direct  consequences.  In  such  cases  we  find 
that  at  a  certain  period  in  their  lives  a  mental  change  took 
place.  In  some  way  their  "  characters  "  underwent  an  altera- 
tion.    In  my  experience  by  far  the  greater  number  of  the 


144  STATES  OF   MENTAL  EXALTATION. 

cases  of  "  moral  insanity "  were  of  this  kind.  Most  of 
Prichard's  cases  of  moral  insanity  I  look  on  as  examples 
of  simple  mania.  As  we  shall  see,  morality,  with  its  inhibi- 
tion of  lower  instincts  and  tendencies,  is  first  lost  in  simple 
mania.  Being  the  last  of  the  great  human  faculties  evolved, 
as  Savage  puts  it,  it  is  the  first  to  he  lost.  It  is  the  highest 
brain  "level"  that  first  undergoes  "dissolution."  Of  course 
I  am  not  referring  to  those  cases  where  no  morals  had  ever 
come  to  a  person  by  heredity,  education,  or  example,  or 
where  the  morals  and  self-control  had  been  dehberately 
destroyed  by  the  mode  of  living. 

Case  of  Simple  Mania,  Change  of  Life,  Immorality,  no  Legal 
Insanity. — I  knew  a  gentleman,  C.  A.,  who  Avas  famed  in  his 
neighbourhood  for  liis  prudence,  probity,  and  devotion  to 
business,  for  his  wisdom,  morality,  and  religion,  who,  at  a 
certain  period  of  his  life,  after  middle  age  had  come  on, 
underwent  a  total  change.  He  became  rash,  indifferently 
honest,  utterly  careless  of  his  business,  foolish  in  his  schemes, 
very  doubtfully  moral,  and  careless  of  rehgion.  He  changed 
in  his  mode  of  dressing,  in  the  company  he  kept,  and  his 
way  of  living.  His  affairs  got  entangled,  and  he  lost  a 
fortune  by  foolish  speculation,  this  being  entirely  new  to 
him.  Yet  he  mingled  in  society  all  the  time;  never  said 
a  particularly  foolish  thing ;  transacted  business  in  a  large 
way  of  the  utmost  importance  to  himself  and  others;  and 
I  should  have  been  very  sorry  indeed  for  any  one  who  had 
called  him  insane  to  his  face,  or  taken  steps  to  abridge  his 
personal  liberty  or  deprive  him  of  his  civil  rights  as  a 
citizen.  ITo  jury  in  the  empire  but  would  have  held  him 
sane,  and  no  judge  but  would  have  made  his  case  a  text 
for  a  homily  on  the  danger  of  medical  views  in  regard  to 
insanity  and  the  liberty  of  the  subject.  I  venture  to  say 
that  you  will  not  have  been  in  practice  for  many  years 
before  you  wOl  have  seen  men  and  women  whose  conduct 
will  be  utterly  inexplicable  except  on  the  theory  that  it  is 
the   result   of   a   morbid   brain   condition,  —  "  motives,"   as 


STATES   OF   MENTAL   EXALTATION.  145 

ordinarily  understood,  having  little  to  do  with  it.  Well, 
C.  A.  got  through  his  fortune,  ruined  his  reputation,  and 
scandalised  and  estranged  his  friends,  all  without  any 
"  motive "  of  the  ordinary  kind ;  and  all  this  came  on 
suddenly  and  in  entire  opposition  to  the  whole  tenor  of 
his  life  and  to  every  principle  that  had  ever  held  sway 
over  him  for  twenty  years.  Yet  legally  sane  he  was,  just 
because  the  brain  change  that  I  assume  was  the  cause  of 
all  this  did  not  go  far  enough  to  make  him  lose  his  self- 
control  entirely,  and  to  act  manifestly  as  a  lunatic.  But, 
can  any  one  who  has  studied  mind  from  the  brain  point 
of  view  doubt  that  the  man's  mental  acts  and  conduct 
during  liis  changed  period  were  morbid,  and  the  result  of 
morbid  brain  action  ?  And  this  conclusion  was  vastly 
strengthened  by  the  fact  that  his  heredity  was  a  nervous 
one,  he  coming  of  a  family  in  which  insanity  and  eccentricity 
had  been  prevalent,  and  that  he  had  procreated  epileptic 
children.  And,  by  tracing  his  future  life,  we  find  that, 
still  without  any  "motive,"  he  again  changed  and  settled 
down  into  a  quiet-going,  slightly  senile  man,  with  the  fine 
edge  of  his  faculties  and  dispositions  somewhat  taken  off. 
In  this,  as  in  several  others  similar  that  I  have  met  with, 
such  a  mild  attack  of  mania  came  on  shortly  after  widow- 
hood. I  have  seen  this  in  both  sexes.  My  idea  is  that 
this  was  not  a  coincidence,  but  that  the  sudden  deprivation 
of  sexual  intercourse  had  something  to  do  with  it  in  this 
case  as  an  exciting  cause. 

Such  is  an  example  of  simple  mania  in  its  mildest  form, 
not  being  reckoned  insanity  at  all  by  the  law  or  by  society. 
You  may  perhaps  save  a  fortune,  or  a  reputation  sometimes, 
and  will  certainly  save  much  uncharitable  recrimination  and 
useless  indignation  on  the  part  of  relations  by  putting  them 
in  possession  of  your  knowledge.  When  I  am  consulted 
in  such  cases  now,  I  often  recommend  a  long  sea  voyage 
in  a  slow  ship,  or  a  change  of  residence  for  a  time,  and 
try  and  get  business  matters  settled  on  some  sort  of  sure 

K 


146  STATES  OF  MENTAL  EXALTATION. 

footing,  so  that  unsafe  speculation  or  falling  into  the  hands 
of  scoundrels  may  he  avoided.  There  is  no  class  of  case 
where  harpies  seem  to  fix  on  a  man  so  inevitably  as  in  this. 
Such  men  are  easily  led  by  adroit  and  unprincipled  people, 
who  flatter  them  and  take  advantage  of  their  weakness. 
The  sort  of  persons  whom  the  man  in  his  "right  mind" 
would  never  have  associated  with  get  round  him  then.  He 
tends  to  seek  persons  in  a  lower  social  and  ethical  position, 
and  very  often  the  loss  of  his  self-control  is  shown  hy  an 
excessive  use  of  stimulants,  or  by  frequenting  bad  company, 
both  being  mere  symptoms  of  his  mental  disorder.  The 
loAver  and  baser  parts  of  a  man,  kept  under  before,  now 
come  uppermost.  Especially  is  undue  excitation  of  the 
sexual  desire  and  disregard  of  morals  and  appearances  in 
gratifying  it  very  common.  I  have  found  this  to  exist  in 
nine-tenths  of  sach  cases,  I  once  saved  a  business  and  a 
reputation  by  getting  a  man  in  the  begiixning  of  an  attack 
of  mild  mania  to  take  a  partner,  give  up  business  meantime, 
go  to  spend  a  year  with  a  friend  on  a  sheep  farm  in  Austraha, 
live  out  in  the  open  air,  take  much  exercise,  eat  little  animal 
food,  and  take  bromide  of  potassium  in  20-grain  doses  three 
times  a  day.  This,  in  fact,  sums  up  about  all  I  can  tell 
you  in  regard  to  treatment.  The  great  difiiculty  is  that 
such  patients  do  not  know  that  there  is  anything  wrong 
with  them,  and  will  not  believe  it;  in  fact,  are  often  very 
indignant,  and  quarrel  with  you  if  such  a  thing  is  hinted 
at.  They  sometimes  look  well,  but  they  do  not  sleep  well, 
and  all  of  them  are  restless,  and  often  worn-looking.  They 
often  eat  twice  and  thrice  as  much  as  usual,  and  digest 
their  food  well.  They  often  have  their  bowels  moved  twice 
and  thrice  a  day,  even  if  naturally  of  a  costive  habit.  Their 
tastes  usually  change.  They  lose  their  fine  feelings  and 
delicate  perceptions  of  things  in  taste  and  smell  and  sensi- 
bihties.  I  have  known  a  man  who  needed  to  use  highly 
magnifying  spectacles  to  be  able  to  do  without  them,  and 
even  be  able  to  read  small  print,  when  passing  through  an 


STATES   OF   MENTAL   EXALTATION.  147 

attack  of  simple  mania.  In  fact,  I  knew  a  man  who,  as 
the  morbid  brain  excitement  gradually  passed  away,  had  to  use 
spectacles  of  greater  and  greater  magnifying  power.  The 
body  temperature  is  always,  I  have  found,  higher  by  about 
•5°  or  1°  during  such  an  attack. ^ 

The  following  case  of  simple  mania  ivas  one  of  great  interest, 
from  the  natural  power  of  the  brain  affected.     C.  B.  was  a  man 
of   very  high  intellectual  and  scientific  attainments,  with   a 
heredity   to   the   neuroses.     (I   have   attended   two   cousins 
suffering  from  melancholia.)     He  was  of  a  sanguine  tempera- 
ment and  robust  bodily  constitution,  great  mental  energy  and 
acuteness,  prudent,  discreet,  and  held  the  opinions  of  others 
in  great  respect.     He  had  written  much  and  done  very  good 
work.     At  the  age  of  forty-five  he  lost  his  wife,  whom  he 
had  sleeplessly  nursed,  and  within  a  week  proposed  marriage 
to  another   lady,  became   excited,  took   two  girls  out   of   a 
brothel,  got  lodgings  for  them,  tried  to  reform  them,  spent 
money  on  them,  prayed  with  them,  and  slept  with  one  of 
them,  intending,  as  he  said,  to  make  her  his  wife.     And  he  did 
some  work  in  a  sort  of  sporadic  way,  not  sticking  to  anything. 
He  slept  little,  and  kept  very  late  and  irregular  hours.     Then 
he  developed  great  brilliancy  and  social  faculty,  for  which  he 
had   never   been  distinguished   before.     He   especially  hked 
ladies'  society,  and  he  was  witty,  clever,  and  had  a  miractilous 
memory,  indeed  a  better  memory  than  he  ever  had  before. 
(I  knew  one  man  who,  as  he  was  passing  into  mania,  would 
repeat  a  whole  play  of  Shakespeare  or   a   book   of   Milton, 
which   when  well  he  could  not   do.)     He  could  quote   long 
passages   from   every   author  he   had   ever   read.     Then   he 
began   to  evolve  wonderful  schemes  of  all  sorts — not  quite 
insane  schemes,  but  very  nearly  so.     He  got  irritable  with 
those  who  opposed  him,  and  said  they  persecuted  him.     He 
went  and  called  on  all  his  casual  acquaintances  of  any  note, 
and  made  new  acquaintances  on  slight  cause.     He  had  been 

^  "The  Temperature  of  the  Body  in  the  Insane,"  Jour.  Ment.  Sci., 
April  1868. 


148  STATES   OF   MENTAL   EXALTATION. 

very  fond  of  his  cliildren  before,  and  now  lie  spoke  mucli  of 
his  affection  for  them,  but  really  he  neglected  them.  He 
quarrelled  with  his  relatives  because  they  remonstrated  with 
him.  and  tried  to  control  him.  He  exhibited  a  morbid 
expansive  benevolence.  He  gave  away  his  money  foolishly 
to  the  poor,  or  to  anybody  whom  he  thought  needed  it. 
He  propounded  to  the  philanthropists  marvellous  plans  to 
terminate  the  world's  misery.  He  went  one  night  with  liis 
Bible  in  his  hand  to  a  brothel  to  convert  its  inmates  from  the 
error  of  their  ways ;  but,  after  reading  and  prayer,  the  vice 
he  hated  was  in  one  short  hour 

"  Endured,  then  pitied,  then  embraced," 

and  he  had  to  leave  his  Bible  in  pledge,  as  he  had  not 
sufficient  money  in  his  pocket  !  All  those  tilings  he  spoke 
of  openly.  Soon  after  this  his  conduct  became  so  uncon- 
trolled that  he  was  certified  as  insane  and  sent  to  the  Asylum. 
He  had  succeeded  in  wasting  nearly  all  his  available  means. 
When  he  arrived  he  was  indignant,  and  made  out  that  his 
friends  had  ruined  his  prospects  by  placing  liim  improperly 
in  a  "madhouse."  But  his  indignation  was  transient  and 
skin-deep.  He  soon  entered  into  the  life  of  the  place.  He 
was  an  admirable  and  interesting  talker,  a  copious  and 
sparkHng  author  in  the  Moi'ningside  Mirror,  a  hearty  if  not 
an  elegant  dancer,  a  great  walker,  a  scientist,  and  a  devoted 
admirer  of  all  the  fair  sex,  making  love  indiscriminately  to 
lady  patients,  nurses,  kitchenmaids,  and  paupers.  And  yet 
he  could  propound  maxims  as  wise  as  Solomon's  proverbs, 
and  he  was  a  stern  and  sarcastic  censor  of  morals  in  others. 
But  he  had  no  common  sense ;  and  he  could  not  help  making 
a  fool  of  himself  if  he  had  the  chance.  He  could  not  be 
trusted  anywhere  out  of  the  Asylum.  He  talked  about  his 
most  private  concerns  to  any  one  who  would  listen  to  him. 
He  was  very  credulous,  and  in  conduct  he  showed  small 
realisation  of  the  difference  between  meum  and  tuum,  or  of 
the   sanctity   of   the   virtues   generally.       His   memory   was 


STATES   OF   MENTAL  EXALTATION.  149 

prodigious  but  not  exact;  and  lie  was  never  at  rest.  His 
sexual  appetites  were  strong,  but  not  really  so  strong  as  his 
erotic  imaginations  and  likings.  He  told  most  disgusting 
stories  "for  a  moral  purpose"  to  others,  and  he  was  better 
up  in  the  sexual  history  of  great  men  than  any  man  I  ever 
knew.  After  having  one  morning  abused  me  most  heartily, 
he  sent  towards  evening  a  letter  addressed — "Immediate. 
The  sun  has  not  gone  down.  Morningside.  From  my 
prison,  where,  like  Joseph,  and  Peter,  and  Paul,  I  was  put 
on  false  accusations.  My  dear  Clouston,  I  beg  your  pardon 
for  speaking  to  you  and  of  you  as  I  have  done.  I  want  some 
liberty.  Try  and  let  some  patients  out,  and  you  will  become 
the  greatest  man  of  the  day.  Give  the  excited  ones  sedatives 
like  tobacco  or  better  food.  Dismiss  such  men — et  audi 
alteram  partem,  that  is,  hear  my  version  of  things.  Let  me 
get  to  town  to-day.  I  need  a  change.  Think  who  I  am. 
Since  1847  the  friend  of  Thomas  Carlyle  and  Alfred 
Tennyson;  of  Owen  since  1838;  of  Darwin,  of  Sir  John 
Richardson,  Rae,  &c.,  &c.,  &c."  (He  had  casually  met 
these  men  or  called  on  them  as  he  was  becoming  ill.) — 
"Yours  ever. 

"P.yS. — Why  have  you  not  shown  me  your  children?  I 
do  not  bite,  I  only  bark. 

"  P.P.S. — Eead  this  to  any  one  who  may  be  concerned." 

Persons  labouring  under  simple  mania  always  think  them- 
selves in  the  right,  and  are  very  sensitive  to  criticism  and 
indignant  at  it.  There  is  much  of  what  one  can  only  call 
cunning.  C.  B.  could  control  himself  for  short  periods  when 
he  wished,  or  when  self-control  was  to  bring  any  advantage ; 
he  would  pretend  to  be  most  friendly  with  the  powers  that  be, 
in  the  Asylum,  before  their  faces,  and  then  turn  and  abuse 
them  behind  their  backs.  He  would,  to  strangers,  most 
cleverly  make  things  appear  extreme  hardships  that  he  did 
not  feel  as  such.  He  ate  enormously  and  slept  badly,  but 
did  not  fall  off  very  much  in  flesh. 

After  six  months  he  was  so  much  better  that  he  was  sent 


150  STATES   OF  MENTAL  EXALTATION. 

to  a  distant  part  of  the  country,  Avliere  he  stayed  for  far  too 
short  a  time.  He  made  an  unsmtable  marriage  with  a 
woman  below  himself  in  social  station  and  education,  had 
children  by  her,  but  soon  got  tired  of  her,  saying  she  was  a 
prostitute.  He  then  Hved  an  eccentric  life  for  twelve  years, 
getting  syphilis,  as  he  said,  from  "using  an  unclean  handker- 
chief " !  At  the  end  of  that  time  he  had  another  attack  of 
simple  mania  of  the  same  general  character  as  the  one 
described,  but  all  the  symptoms  more  severe.  He  was  more 
incoherent,  less  brilliant,  less  interesting,  more  disgustingly 
immoral — his  brain,  in  fact,  had  the  fine  edges  of  all  its 
quahties  taken  off.  He  died,  after  a  few  years,  still  maniacal, 
and  with  some  of  the  mental  enfeeblement  of  dementia. 

Such  a  patient  must  be  regarded  as  suffering  from  simple 
mental  exaltation  with  mild  excitement,  the  result  of  a 
hereditary  instability  of  brain.  ]My  behef  is  that  brain- work 
and  education  tend  towards  this  condition  in  those  predisposed. 
One  cannot  speak  dogmatically,  but  I  think  if  such  a  man's 
brain  had  never  been  highly  educated,  or  if  he  had  not  taken 
to  intellectual  work,  or  even  if  his  wife  had  Hved,  he  might 
never  have  developed  the  morbid  brain  elevation  at  all.  It 
might  have  remained  all  his  Life,  as  it  had  done  for  forty -five 
years,  a  mere  potentiaUty.  Such  cases  are  very  difficult  to  treat 
and  manage.  They  will  not  be  controlled  outside  an  asylum, 
they  create  scandal  and  waste  money,  yet  it  is  for  a  long 
time  impossible  to  certify  them  as  insane ;  and  when  sent  to 
asylums  it  is  undoubtedly  hard  on  them,  for  they  are  sensible 
and  irritable,  and  capable  of  enjoying  life  to  a  large  extent. 
Such  attacks  are  usually  over  six  months  in  duration,  but  I 
have  seen  them  very  transitory  and  pass  away  within  six 
weeks.  I  do  not  know  any  method  as  yet  to  influence 
favourably  such  morbid  energising  of  the  brain  except  quiet, 
fresh  air,  non-stimulating  food,  warm  baths  at  night,  the  use 
of  sulphonal  in  small  doses,  or  the  bromides. 

ITie  following  case  of  simple  mania,  of  short  duration,  was 
undoubtedly  benefited  by  restraint  in  an  asylum.     It  was  that 


STATES  OF  MENTAL   EXALTATION.  151 

of  C.  C,  a  member  of  a  learned  profession,  aged  59,  of  a 
sanguine  temperament,  and  cheerful  and  frank  disposition  and 
good  bodily  health,  good  habits,  and  no  hard  work.  He  had 
been  morbidly  excited  in  mind  on  four  or  five  previous  occa- 
sions, the  excitement  passing  off  in  six  weeks,  being  treated 
by  his  being  sent  off  to  a  lonely  country  place  to  "  walk  it 
off"  among  the  hills.  There  was  no  admitted  or  known 
heredity  (such  facts  in  family  histories  are  kept  very  secret 
and  are  soon  forgotten,  so  that  they  are  often  really  not  known 
to  the  younger  members  of  a  family),  except  that  his  mother 
had  been  in  a  state  of  senile  dotage  for  ten  years  before  her 
death  at  a  very  advanced  age.  Six  weeks  before  admission 
he  had  become  changed  in  disposition,  altered  in  conduct, 
unsettled,  much  elevated,  always  talking  about  the  Turco- 
Servian  war  that  was  going  on  then,  restless,  sleepless,  changed 
in  his  appetites  and  tastes  for  food,  and  he  began  to  dress  in  an 
entirely  different  way  from  what  was  natural  to  him.  In  his 
case  the  most  striking  alteration  was  in  his  truthfulness. 
Katurally  a  truthful  man,  when  his  illness  began  he  took  to 
telling  lies  by  wholesale  about  everything,  and  for  no  purpose 
or  "  motive."  He  was  boastful  to  absurdity,  bragging  of 
qualities  nearly  the  opposite  to  those  needed  in  his  profession. 
This  human  nature  tendency  to  be  very  proud  of  things  out  of 
one's  hne — the  lawyer  of  his  medical  skill,  the  parson  of  his 
worldly  wisdom — you  will  find  in  an  exaggerated  degree  in 
mania.  He  was  a  marvellous  swimmer,  a  splendid  boxer ;  he 
would  dilate  with  circumstantial  detail  on  the  numbers  of 
expert  swordsmen  he  had  overcome  and  killed,  and  on  the 
pugilists  he  had  thrashed  to  within  an  inch  of  their  Hves.  He 
said  he  was  going  out  to  the  war,  and  would  soon  be  made  the 
general  of  the  Servians,  and  he  actually  purchased  some  appro- 
priate weapons.  Yet  there  was  a  little  method  in  his  madness, 
for  he  was  somewhat  careful  about  whom  he  told  those 
wonderful  tales  to,  and  his  manner  of  telling  them  was  not 
quite  that  of  a  lunatic  who  fully  believed  them.  He  drank 
too  much,  and  his  habits  were  not  orderly  or  cleanly.     An 


152  STATES   OF   MENTAL   EXALTATION. 

liour  before  lie  was  taken  to  the  Asylum  he  had,  to  some 
persons,  of  whom  I  was  one,  whom  he  thought  congenial 
spirits,  told  his  best  stories,  and  had  exhibited  a  mixture  of 
extravagance,  hes,  boastfulness,  and  obscenity  that  quite 
convinced  two  of  the  company  (doctors  there  to  examine  him) 
that  he  was  very  insane,  and  they  certified  him  at  once. 
From  the  way  he  had  been  talking,  those  who  took  liim  to 
the  Asylum  were  prepared  for  a  desperate  resistance.  But 
there  was  nothing  of  the  kind.  With  a  verbal  protest,  and 
a  manner  as  meek  as  Moses,  with  no  resistance  and  no  fight 
at  all,  this  wondrous  pugihst  went  to  the  Asylum.  He  collapsed 
at  once,  and  his  whole  effort  was  to  explain  away  his  conduct, 
and  apologise  for  his  language.  It  seemed  to  act  like  a  charm 
on  him,  and  to  restore  much  of  his  power  of  self-control.  He 
again,  and  at  once,  assumed  the  speech  and  manner  of  an 
elderly  parson — this  pugihst  of  an  hour  before.  And  he 
never  again  indulged  in  quite  such  violent  speech,  or  exhibited 
such  extraordinary  conduct,  though  he  dressed  queerly  for  a 
few  weeks,  did  not  sleep  Avell,  and  was  elevated  in  his  de- 
meanour. He  tried  hard  to  attach  unreal  meanings  to  his 
tales,  and  to  apologise  for  his  extravagant  conduct.  In  three 
months  he  Avas  quite  well,  and  kept  well  for  several  years, 
when  he  had  another  very  mild  attack,  and  this  time  his 
morbid  energy  found  an  outlet  in  pubhshing  a  book.  I"he 
sudden  puUing  of  himself  up  by  a  patient  on  being  taken  to 
an  asylum  is  often  seen,  both  in  mania  and  in  melanchoHa, 
but  it  does  not  always  last.  The  brain  pace  breaks  out  again, 
and  sometimes  far  harder  than  before,  because  at  home,  per- 
haps before  children,  as  much  self-control  as  possible  is 
exercised,  while  in  an  asylum  a  man  frequently  thinks  there 
is  no  object  in  exercising  it  and  does  not  do  so. 

In  other  cases  of  simple  mania  a  morbid  vanity  is  eichihited, 
as  in  the  following  case,  I  have  no  doubt  that  the  weak  points 
of  normal  character  are  those  that  are  usually  exaggerated  in 
simple  mania : — C.  D.,  a  tradesman,  was  sent  as  a  patient  to 
the  Eoyal  Edinburgh  Asylum,  and  at  first  he  seemed  to  be 


STATES   OF   MENTAL  EXALTATION.  153 

merely  a  talkative  and  egotistical  old  gentleman.  But  it  soon 
appeared  that  authorsliip,  and  poetry  in  particular,  was  his 
special  weakness ;  while,  along  with  this,  there  was  a  peacock- 
like vanity  in  dress  and  demeanour  that  was  very  ludicrous. 
By  a  pompous  manner,  a  sesquipedalian  speech  intended  to  be 
impressive,  a  combination  of  the  juvenile  and  the  Byronically 
poetic  in  dress,  and  a  very  big  book  always  carried  under  his 
arm,  he  showed  his  morbid  vanity.  He  was  most  touchy  when 
interrupted  in  his  long  speeches,  and  he  tried  to  be  very  wither- 
ing in  his  contempt.  He  used  to  write  me  a  letter  of  fifty 
pages  of  foolscap  in  the  prosiest  style  if  he  had  a  simple  matter 
to  bring  under  my  notice.  Indeed,  his  speeches,  which  he 
tried  to  inflict  on  me  every  day,  used  to  try  me  pretty  nearly 
up  to  the  point  of  my  own  power  of  endurance,  though  I  am 
pretty  well  seasoned  in  the  art  of  bearing  fools  gladly.  His 
poetry  was  trash,  which  he  produced  by  the  ream,  thinking  it 
was  equal  to  Shakespeare's,  and  he  tried  to  read  it  with  due 
dramatic  effect  to  the  ladies  in  the  drawing-room  in  the  even- 
ings. Yet,  with  all  this,  he  was  not  incoherent.  He  had 
periods  of  intensified  excitement,  when  he  would  scold  much. 
He  was  very  thin  when  admitted,  and  his  nervous  and  nutritive 
power  and  tone  low,  so  I  fed  him  well,  gave  liim  a  liberal 
allowance  of  good  London  porter,  extra  milk,  and  cod-liver 
oil,  and  insisted  on  his  being  in  the  open  air  most  of  the  day. 
He  got  fat ;  and  as  this  took  place  his  foolish  vanity  and  ex- 
citabihty  diminished,  and  he  grew  into  a  moderately  rational 
human  being,  who  left  the  Asylum  with  the  full  intention  of 
returning  to  his  business.  But  the  loss  of  external  control 
seemed  hke  taking  ofi"  the  governors  of  a  steam-engine ;  he  got 
thin,  poetic,  and  morbidly  vain,  and  had  to  be  sent  to  another 
asylum,  where  surely  they  did  not  give  him  as  much  paper  as 
we  did,  for  he  abused  the  place  most  heartily,  and  wanted 
badly  to  come  back  to  Morningside,  but  we  had  no  room  for 
liim,  and  he  died  in  a  year  or  two,  still  insane. 

/  have  met  loith  cases  of  simple  mania  ivliere  the  Jack  of  con- 
troUing  power  was  seen,  not  so  much  in  speech  or  ordinary  con- 


154  STATES   OF   MENTAL   EXALTATION. 

duct  as  in  loant  of  muscular  inliihition.  I  liad  a  young  lady, 
C.  E.,  under  my  care  once,  ■who  came  of  a  very  nervous  family, 
and  whose  brother's  case  I  have  referred  to  (A.  D,,  p.  38)  as  ex- 
hibiting such  morbid  indecision  and  paralysis  of  volition  that  he 
could  not  make  up  Ms  mind  which  stocking  to  put  on  for  half 
an  hour.  She  seemed  perfectly  well  when  one  spoke  to  her, 
but  when  left  alone  she  would  make  faces,  jump  about,  tear 
her  clothes,  turn  heels  over  head,  scream,  pick  her  skin,  and 
masturbate  apparently  automatically  without  much  erotic 
intent  or  much  sexual  feeling.  In  the  midst  of  all  this,  if 
one  addressed  her  she  would  sit  up  and  talk  as  intelligently 
and  quietly  as  possible.  She  had  no  delusions,  no  tendency 
to  violence,  and  was  gentle  and  lady-hke.  She  came  into  the 
Asylum  as  a  voluntary  patient,  and  declared  she  could  not 
restrain  these  movements.  Like  chorea,  they  were  apt  to 
come  on  in  an  aggravated  way  at  the  menstrual  periods. 
They  were  unlike  choreic  movements  in  their  real  character, 
being,  if  one  might  use  a  contradiction  in  terms,  automatically 
volitional.  She  did  not  sleep,  and  could  not  employ  herself 
for  any  length  of  time.  She  recovered  from  the  first  of  these 
attacks  in  a  few  months,  but  then  had  a  more  severe  one,  on 
which  no  treatment  had  any  permanent  effect,  and  she  got 
thinner  and  more  attenuated,  and  died  of  exhaustion  in  about 
two  years.  She  was  free  from  delusions,  and,  in  a  way,  intel- 
lectually sound  up  to  the  last,  during  the  periods  when  she 
picked  herself  up.  Every  sort  of  treatment  was  adopted, 
everything  to  fatten  and  improve  the  nerve  tone  that  we 
could  think  of — cod-liver  oil,  maltine,  the  phosphates,  hypo- 
phosphites,  arsenic,  strychnine,  &c.  All  the  usual  sedatives 
and  narcotics  were  tried — the  bromides,  opium,  henbane, 
cannabis  indica,  lupuHne,  camphor.  She  was  anaesthetised  by 
ether  and  chloroform.  She  had  blisters,  warm  baths,  exercise 
almost  to  exhaustion,  &c. 

That  was  an  extreme  and  pure  example  of  a  symptom 
which  we  see  commonly  enough  in  mania,  viz.,  automatic  co- 
ordinated   movements    that   are    ordinarily   voluntary,    but 


STATES   OF   MENTAL   EXALTATION.  155 

result  evidently  from  morbid  exaltation  of  function  in  the 
liighest  motor  centres  in  the  convolutions.  It  is  a  muscular 
mania,  the  intellectual  and  volitional  power  being  compara- 
tively intact,  but  the  highest  ideo-motor  inhibitory  centres 
being  paralysed.  It  Avas  a  curious  fact  that  her  brother  should 
have  been  affected  in  such  a  different  and  psychologically  con- 
trasted way, — in  the  one,  the  will  not  being  able  to  put  the 
muscles  into  action,  in  the  other,  not  being  able  to  stop  them. 
I  said  that  simple  mania  assumes  the  form  of  "  moral 
insanity  "  at  times,  without  apparent  intellectual  aberration. 
The  system  of  checks  on  inclination,  doing  duty  for  its  own 
sake,  and  efforts  after  the  good,  lohich  by  the  constant  strivings 
of  years  has  hecome  a  habit,  and  constitutes  the  man^s  moral 
character,  sometimes  vanishes  like  the  early  dew  at  the  begin- 
ning of  an  attach  of  mania.  I  shall  give  an  example.  C.  F., 
a  lady  of  good  education,  good  morals,  refined  disposition, 
and  lady-hke  tastes,  had  several  attacks  of  mental  disease,  of 
wliich  the  following  were  always  the  symptoms  : — She  slept 
much  less  than  usual,  and  got  tliinner.  Her  expression  of 
face  changed.  Instead  of  being  a  pleasant-looking  woman, 
her  features  acquired  a  coarser  look.  She  ate  twice  as  much, 
and  lost  the  delicate  ways  of  a  lady.  She  lied,  stole,  whored, 
and  took  pleasure  in  annoying  or  hurting  every  person  she 
came  across.  She  was  cruel  to  animals.  She  was  such  a 
blister  and  firebrand  that  she  could  live  in  no  private  house 
with  others,  and  in  the  Asylum  she  could  set  up  ten  patients 
in  as  many  minutes.  She  had  the  most  extraordinary  instinct 
in  finding  out  the  weak  points  of  her  fellow-creatures  I  ever 
saw,  and  she  remorselessly  used  this  for  their  annoyance, 
this  being  her  chief  dehght.  She  did  not  court  a  fight,  but 
never  declined  one  with  any  person  whom  she  had  roused 
to  fury,  enjoying  it  too ;  and  yet,  with  all  this,  she  was 
plausible,  always  with  a  ready  excuse  for  her  scrapes,  could 
make  herself  most  agreeable  at  an  evening  party,  and  would 
have  defied  any  doctor  to  find  facts  indicating  insanity  in  an 
hour's  conversation.     It  was  only  by  watching  her  conduct 


156  STATES   OF   MENTAL   EXALTATION. 

that  sucli  facts  could  be  got,  and  she  could  be  certified.  She 
was  such  a  nuisance  that  asylums  passed  her  on  from  one  to 
the  other  as  too  troublesome  to  keep,  though  she  seldom  got 
into  a  rage  or  became  outwardly  excited.  And  all  this  came 
on  her  at  intervals  like  any  other  disease,  passing  off,  and 
leaving  her  the  same  refined  moral  and  pleasant  lady  she  had 
ever  been. 

Case  of  Sudden  Immorality  in  a  Girl. — I  had  once  under 
my  care  a  girl,  C,  G.,  aged  17,  the  daughter  of  a  gentleman, 
her  mother  being  intemperate.  Had  been  well  brought  up, 
and,  up  to  within  a  week  of  her  admission  to  the  Asylum,  a 
weU-conducted  girl.  She  was  of  a  robust  and  perhaps  rather 
sensual  constitution,  who,  without  showing  any  previous  sign 
of  insanity,  except  conduct  that  was  called  wayward  and  dis- 
obedient, left  her  home,  wandered  to  where  some  workmen 
lived,  m  a  lonely  place  many  miles  off,  and  passed  the  night 
Avith  them.  She  showed  no  other  signs  of  mania,  when  taken 
home,  than  utter  disregard  of  her  parents'  feelings,  bad 
language  and  violence  to  them,  want  of  right  feeling  of  any 
sort,  and  threats  to  commit  suicide.  Those  symptoms  were 
recognised  as  constituting  insanity,  and  she  was  sent  to  the 
Asylum.  This  state  of  matters  passed  off  in  a  few  days,  and 
she  became  apparently  well  in  all  respects,  except  that  she 
seemed  blunted  in  her  feehngs,  incapable  of  applying  herself 
to  any  work,  and  at  times  sullen  and  stupid.  Her  catamenia 
had  been  irregular,  and  she  had  suffered  from  severe  head- 
aches before  the  attack.  She  remained  free  from  excitement, 
though  not  considered  well,  for  about  six  weeks,  when,  just 
before  menstruation,  and  preceded  by  frightful  cephalalgia 
and  a  day  or  two  of  dulness  and  mental  torpor,  she  had  an 
acutely  maniacal  attack  of  great  violence,  coming  on  like  an 
explosion,  and  lasting  for  a  few  days.  She  had  three  of  those 
within  a  month ;  then  she  had  in  the  next  two  months  several 
suUen  stupid  attacks.  In  five  months  she  recovered.  Each 
maniacal  attack  was  accompanied  by  a  foul  tongue,  deranged 
bowels,  flushed  face,  and  total  loss  of  memory  and  power  of 


STATES   OF   MENTAL   EXALTATION.  157 

attention.  After  she  recovered  she  had  no  recollection  of  any- 
thing that  occurred  during  the  attack.  Thus  the  immorality 
and  the  disobedience  and  disregard  of  her  parents'  wishes  were 
clearly  shown  to  have  been  symptoms  of  an  attack  of  simple 
mania  which  preceded  the  three  acute  attacks. 

Case  of  Maniacal  Immorality  in  a  Boy. — I  once  saw  a  boy, 
C.  H.,  of  14,  whose  father  was  a  drunkard,  Avife-beater,  and 
of  a  most  ungovernable  temper,  though  a  clergyman,  and  his 
mother  a  down-trodden,  rather  soft  woman,  his  elder  brother 
being  just  like  the  father.  His  father  used  to  make  C.  H. 
drink  when  a  mere  boy,  and  taught  him  to  smoke.  When  a 
child,  he  had  been  of  a  very  ungovernable  temper,  utterly 
undisciplined,  and  disobedient,  assaulting  his  mother,  swear- 
ing, shouting,  breaking  open  locks,  knocking  about  furniture, 
threatening  to  shoot  first  his  sisters  and  then  himself,  buying 
,a  pistol  and  practising  with  it.  He  could  not  be  got  to  go  to 
school,  or  to  do  anything  useful.  His  habits  were  irregular. 
He  would  stay  in  the  house  for  weeks  at  a  time,  and  was 
unsocial  and  unplayful.  When  I  saw  him  he  was  quiet  and 
apparently  reasonable.  He  was  a  delicate,  nervous-looking 
boy,  with  a  restless  elevated  expression  of  eye  and  face. 
When  I  said  he  would  be  sent  to  sea  if  he  did  not  behave 
better,  he  replied  the  man  who  came  for  him  would  get  the 
contents  of  his  revolver.  I  recommended  that  he  should  go 
and  travel  with  a  sensible  tutor,  and  this  was  attended  with 
benefit  to  him. 

ISTot  only  are  the  morals  affected,  but  the  whole  character 
is  altered.  I  have  seen  some  people  improved  vastly  in 
certain  respects  during  a  shght  attack  of  simple  mania.  I 
knew  a  naturally  reserved,  proud,  unsocial,  rather  cantankerous, 
selfish,  stupid,  miserly  man  become  for  a  time  genial,  bright, 
good-mannered,  and  generous  during  such  an  attack.  The 
changes  in  the  tastes,  instincts,  and  even  in  the  organic 
appetites  are  often  marked  and  most  peculiar.  Most  patients 
do  not  like  the  same  food  as  when  in  health.  They  often 
take    to    excessive    smoking,    and    sometimes    to    drinking, 


158  STATES   OF   MEXTAL  EXALTATION. 

independently  of  their  lia"bits  in  those  respects  when  in  health. 
The  dehcate  likings  are  not  only  lost,  hut  new  repugnances 
develop  themselves,  and  former  friendships  are  commonly 
altered  or  lost.  The  personal  hahits  tend  to  become  untidy, 
slovenly,  and  dirty  ;  iinconventionahties  of  all  sorts  are  in- 
dulged in — and,  hy  the  way,  this  applies  to  most  of  the 
insane — if  these  things  are  not  looked  to  and  corrected. 

The  higher  iutellectual  tastes  also  change.  I  knew  a  man 
who  could  not  appreciate,  and,  as  a  matter  of  fact,  neglected 
his  favourite  authors,  taking  to  their  exact  opposites.  When 
well,  he  read  Gibbon  and  Hume ;  when  iU,  he  took  to  Biirns 
and  Swinburne. 

The  sort  of  brain  evolution  into  insanity  at  an  early  age, 
which  the  Germans  have  called  "  Primdre  Verrucktlieit,"  in 
which  changes  of  character,  fooHsh  insane  conceits,  wayward- 
ness, unreasoning  extravagances,  unsocialness,  gradually 
develop  into  delusional  insanity  or  dementia,  may  at  the 
beginning  usually  be  classed  as  simple  mania.  ]Many  cases  of 
"Paranoia"  seem  to  be  of  this  character,  Avith  or  without 
delusion.  The  Folie  raisonnante  of  the  French  corresponds 
in  a  general  way  to  the  milder  cases  of  simple  mania. 

Simple  mania  is  very  often  the  first  stage  of  acute  mania, 
which  we  are  to  consider  next.  The  following  letters  of  a 
young  unmarried  man,  C.  J.,  who  naturally  was  of  a  modest, 
rather  shy,  disposition,  but  who  had  for  a  month  laboured 
under  simple  mania  with  strong  exaltation  of  the  nisus 
generativus,  and  was  passing  into  acute  mania,  Ulustrates  the 
mental  condition  of  such  a  person.  The  first  two  letters  are 
elevated  and  delusive,  but  nearly  coherent ;  the  third,  a 
month  afterwards,  very  much  more  extravagant. 

Edinburgh,  7th  December. 

Dear  Dr  CLorsTOX, — I  had  a  good  night's  sleep  hist  night  after  the 

pleasant  evening  I  had,  and  feeling  sure,  after  the  kindness  I  have  met 

with  here,  that  the  best  way  of  getting  a  perfect  cure  is  to  make  a  clean 

breast  of  it,  I  now  try  to  do  so.     I  believe  that  I  am  a  married  man,  and 

that  a  lady  called  Miss ,  the  reputed  daughter  of ,  is  really 

my  wife,  further  that  she  has  had  children  by  me,  one  of  which  is  dead. 


STATES   OF   MENTAL   EXALTATION.  159 

I  believe  I  have  ten  children  by  her  still  alive,  three  of  whom  I  used  to 

believe  the  children  of  my  late  uncle ,  who  now  live  with  his  widow 

at ,  four  who  were  brought  up  by  ,  and  three  who  were 

brought  up  by  my  reputed  parents'  friends .     I  have  long  had 

this  belief,  but  not  having  any  proof  but  instinct  to  guide  me,  I  refrained 
from  stating  it.  I  believe  it  is  true.  Should  it  not  be  so,  why,  it  only 
proves  my  love  for  her  and  them,  and  I  feel  sure  you  will  try  and  cure 
me  of  the  delusion.     I  write  as  one  Christian  to  another  older  and  more 

experienced  one. — With  all  respect  and  confidence, — Yours . 

Tth  December. 

Deak  De,  Clouston, — In  my  last  letter  I  put  the  cart  before  the 

horse.     I  believe  Mr (a  fellow  patient)  to  be  Duke  Constantine, 

my  father  and  Miss to  be ,  but  I  am  wrong  there  I  think. 

— Yours  faithfully . 

MoBNiNGsiDE,  EDINBURGH,  ?>th  January. 

My  Dear  Old , — I  have  at  last  fallen  in  love  with  the  prettiest 

girl  you  ever  saw.  I  got  j'our  letter,  thanks,  old  man,  and  the  quota- 
tions which  I  enjoyed,  and  went  to  look  for  it  in  an  old  coat,  but 
couldn't  find  it — well  but  this  girl  you  know  I'm  a  bit  of  a  student  and 
a  selfish  brute,  but  for  all  that  I  love  the  girl,  you  may  call  a  thing  two 
names,  but  it's  the  same  nearly  ? 

Now  the  fact  of  the  matter  is  they  are  so  uncommon  kind  to  a  fellow 
here  women  and  men,  it's  a  fact,  but  then  I  was  far  far  below  the  normal 
point  of  sanity,  that  even  although  I  was  doomed  to  remain  here  all  my 
natural  life,  I  could  do  it  with  ups  and  downs,  but  you  see  this  girl, 

.     "Were  I  pronounced  sane  enough  to  be  out,  she  might  have  me. 

The  fact  is, ,  I'm  such  another  uncommon  agreeable  fellow  at  times, 

but  then  it's  the  liver,  as  an  Irish  friend  of  mine,  that  I  suspect  one  may 
say  it  as  a  joke.     Dr  Clouston,  who  paints  his  face,  keeps  me  here  as  a 

profit  to  the  concern.     Now  this  girl  — ^ .     If  in  a  fortnight  Clouston 

doesn't  let  me  up  to  Craighouse,  that's  the  superior  house  where  we  get 
tarts,  but  there  is  a  very  black  hole  of  a  boot-house  yet,  would  you  as  an 
S.S.C,  is  it,  or  no,  a  writer,  take  up  my  case  as  a  sane  man,  for  the  girl's 
sane  you  know.  I  have  enough  to  pay  you  some  £1600  I  think  and 
over,  and  I'll  spend  it  all  for  the  sake  of  the  honour  of  the  sex. 

The  Christians  here  all  love  one  another,  though  we  fight  at  times 
like  the  Kilkenny  cats,  but  try  afterwards  and  bury  one  another's 
remains  for  the  sake  of  the  health  of  the  remainder.  There  are  a  few 
dear  little  children  here,  pigs,  and  rabbits. 

I'll  let  you  hear  iu  a  fortnight,  if  the  powers  will  let  the  epistles  pass. 

You  never  sent  me  marriage  cards. — Your  aff.  friend. 

P.  ,S'.— How's  the  little  boy. 

Acute  Mania — The  "raving  madness"  of  the  older  authors, 
or  acute  mania,  is  perhaps  the  type  of  all  insanity,  both  in 


160  STATES   OF   MENTAL   EXALTATION. 

the  popular  and  professional  mind.  Eeing  tlie  least  rational, 
least  conscious,  most  noisy,  most  unmanageable,  and  some- 
times the  most  dangerous  variety  of  mental  disease,  it  affected 
the  conceptions  and  the  treatment  of  all  other  varieties  in  a 
most  unfavourable  way.  In  it,  many  patients  had  no  more 
"  reasoning  power  than  a  wild  beast,"  and  all  persons  con- 
cluded to  be  insane — the  conception  of  insanity  was  then  a 
much  narrower  one,  embracing  much  fewer  persons — were 
accordingly  treated  by  manacles  and  chains,  stripes  and  dark- 
ness. Small  compassion  was  felt  for  them,  few  laws  protected 
them,  little  medical  skill  or  study  was  exercised  in  their 
behalf,  for  they  were  reckoned  beyond  the  pale  of  ordinary 
humanity.  Even  in  Esquirol's  time,  at  the  beginning  of  this 
century,  such  patients  are  pictured  in  wild  contortion  and 
fury  of  look  and  action,  and  are  represented  heavily  bound 
in  his  illustrations.  Yet,  this  is  a  type  of  disease  that  is 
nowadays  not  at  all  so  common  as  others. 

Statistics. — Out  of  the  2377  admissions  into  the  Eoyal 
Edinburgh  Asylum  during  the  seven  years  1874-80,  only  297, 
or  about  8  per  cent.,  were  classified  as  acute  mania,  and  there 
were  not  twenty  of  these  that  could  have  sat  for  Esquirol's 
pictures.  Acute  mania  may  be  defined  as  intense  mental 
exaltation  Avith  great  excitement,  complete  loss  of  self-control, 
with  sometimes  absolute  incoherence  of  speech  and  loss  of 
consciousness  and  memory.  After  twelve  months  it  is  by 
some  authors  arbitrarily  no  longer  reckoned  acute  but  chronic 
mania.  Some  authors  set  up  a  period  of  forty  days,  during 
which  alone  the  disease  was  to  be  called  acute  mania,  but  this 
has  no  foundation  in  any  clinical  fact. 

Inception. — Acute  mania  begins  in  various  ways.  The 
most  common  is  by  its  commencing  as  simple  mania,  and  then 
passing  into  the  acute  form.  But  I  have  seen  it  begin  quite 
suddenly,  the  patient  being  one  hour  a  sane  rational  respon- 
sible being,  and  the  next  acutely  maniacal.  It  often  has  a 
melancholic  prelude.  It  sometimes  begins  by  the  patient's 
expressing  a  delusion  out  of  which,  as  it  were,  the  extra va- 


STATES   OF   MENTAL   EXALTATION.  161 

gances  seem   to   arise.     Sometimes  it  begins   by   emotional, 
sometimes  by  intellectual  exaltations   and  perversions,  some- 
times by  both.     At  other  times  it  begins  by  alterations  of 
habit,  appetite,  and  propensity.     It  commonly  has  premoni- 
tory  symptoms,   bodily   and  mental,   such   as   headaches,   a 
confused  feeling  in  the  head,  a  muscular  fidgetiness,  an  unrest 
of  body  and  mind,  a  feeling  that  something  is  going  wrong 
or  dreadful  is  to  happen,  a  consciousness  of  impending  insanity, 
a  feeling  of  wild  commotion  in  the  head,  as  if  it  were  to 
burst,  an  impulsive  desire  to  do  something,  to  break  glass,  or 
do  violence  to  those  within  reach.     There  is  usually  disturbed 
sleep  and  constant  dreaming,    commonly   of   an   unpleasant 
kind.    I  have  known  the  temperature  to  rise  to  over  100°  be- 
fore even  the  patient  could  be  said  to  be  in  any  way  maniacal. 
All  those  symptoms  in  a  typical  case  are  soon  replaced  by 
great  restlessness  and  muscular  agitation  ;  a  complete  change 
of  emotional  state,  this  often  becoming  very  joyous ;  a  rapid 
and  uncontrolled  passing  of  the  ideas  through  the  mind ;  vivid 
kaleidoscopic  mental  pictures  of  the  past ;  scraps  of  former 
life    and    experience   suggested   by   chance   associations ;    a 
tendency  to  constant  talking  whether  any  one  is  present  or 
not ;  passing  from  one  thing  to  another  and  soon  becoming 
incoherent  of  speech.     The  manner  is  utterly  changed,  being 
usually  jolly  or  fierce.     There  may  be  ceaseless  laughing,  or 
scolding,  or  swearing.     Conversations  are  held  in  loud  tones 
with  imaginary  people  whose  voices  are  sometimes  heard  or 
their  forms  seen.     Sometimes,  too,  there  are  hallucinations  or 
perversions  of  smell  and  touch.     The  common  sensibility  and 
all  the  senses  may  be  hyperaesthetic  at  first,  but  soon  become 
dulled.     Sometimes  there  is  a  rhythmic  action  of  mental  and 
muscular  centres  evinced  by  rhyming  all  the  ordinary  con- 
versation, or  by  regular  movements  of  the  limbs  and  body. 
Frequently  there  is  a  tendency  to  shut  the  eyes  so  as   to 
exclude  the  real  impressions  of  the  senses,  and  live  in  the 
false  consciousness  created  by  the  morbid  energising  of  the 
brain.      Conversations  with   old  friends   now  dead  will  be 

L 


162  STATES   OF   MENTAL   EXALTATION. 

carried  on.  Scenes  of  claildliood  and  years  gone  by  will  be 
vividly  realised.  The  temperature  is  over  99°,  often  over 
100°,  the  pulse  quick  and  sometimes  full,  and  the  skin  moist 
at  this  stage,  the  tongue  getting  furred,  the  appetite  usually 
gone,  the  tastes  and  sense  of  decorum  and  decency  perverted. 
At  the  end  of  this  stage  the  power  of  self-control  may  be 
utterly  lost,  though  by  rousing  him  the  patient  may  by  an 
effort  pick  himself  up  and  talk  and  behave  rationally  for  a 
few  minutes.  The  memory  may  at  this  stage  be  good,  and 
the  patient  remember  afterwards  what  happened  then. 

Delirious  Mania. — A  still  further  stage  is  when  the  patient 
gets  more  actively  excited,  shouts,  sings,  attacks  those  about 
him,  mistakes  their  identity,  calling  them  by  different  names, 
thinks  they  are  "  acting  "  on  him,  rushes  about,  and  would 
sometimes  injure  himself  or  those  near  him.  The  tongue  ■ 
gets  more  and  more  foul  and  soon  dry,  with  sordes  on  the 
teeth  and  lips ;  the  appetite  is  not  only  gone,  but  there  is  a 
strong  revulsion  against  food,  so  that  forcible  feeding  has  to 
be  resorted  to.  The  speech  becomes  absolutely  incoherent, 
and  there  is  no  consciousness,  memory,  power  of  attention,  or 
any  care  for  the  caUs  of  nature.  This  is  the  "delirious 
mania  "  of  some  authors,  which  they  maintain  to  be  a  distinct 
form  of  mental  disease,  and  say  is  a  very  fatal  disease  indeed. 
I  think,  on  the  contrary,  that  the  worst  cases  very  often 
recover. 

Memory,  Incoherence,  Hallucinations,  Illusions. — The  degree 
to  which  there  is  remembrance  afterwards  of  the  events  oc- 
curring during  acute  mania  differs  greatly  in  different  cases. 
The  friends  of  patients  will  usually  be  most  anxious  on  this 
point,  fearing  the  effect,  when  recovery  has  taken  place,  of 
the  recollection  of  being  taken  to  the  asylum,  of  being  fed,  &c. 
I  advise  you  to  be  careful  in  predicting  on  this  point.  In 
some  cases  the  whole  period  of  the  disease  is  a  complete  blank 
afterwards ;  but  more  commonly  things  heard,  seen,  and  ex- 
perienced during  the  almost  delirious  period,  are  remembered 
afterwards  in  a  sort  of  distorted  exaggerated  way.     Patients 


STATES   OF  MENTAL  EXALTATION.  163 

often  remember  and  complain  of  the  restraint  and  the  force 
needed  to  overcome  their  violence,  the  compulsory  walking, 
dressing,  and  feeding,  but  have  no  recollection  of  their  own 
condition  at  the  time  which  made  all  these  things  necessary. 
I  think  that  the  memory  of  events  during  the  disease  is 
regulated  by  the  degree  in  which  the  power  of  attention  is 
unaffected.  In  health  you  know  how  much  memory  depends 
on  attention,  which,  like  a  muscular  act,  implies  much  fatigue 
in  its  prolonged  exercise.  There  may  be  a  presentation  of 
an  object  to  the  eye,  or  a  sound  to  the  ear,  yet  if  there  is  no 
attention  there  is  no  brain  registration,  and  no  after  power  of 
representation  or  conscious  memory.  The  late  Professor 
Lay  cock's  ^  views  in  regard  to  memory,  organic  or  inherited, 
in  regard  to  synesis  or  the  registration  of  an  impression,  in 
regard  to  the  recollection  or  the  act  of  calling  up  the  impres- 
sion to  consciousness  afterwards,  are  very  important  in  our 
study  of  the  clinical  symptoms  of  mania.  The  ravings  of  a 
maniacal  patient  are  often  well  worthy  of  study,  both  as  a 
medico-psychological  problem,  as  affording  an  insight  into  the 
man's  mental  history  and  constitution,  and  as  a  symptom  of 
much  practical  import  to  the  physician.  There  is  seldom  such 
a  thing  as  real  "incoherence."  The  words  and  the  ideas 
cohere  by  some  bond  or  other.  They  always  relate  to  former 
perceptions,  thoughts,  and  experiences,  that  have  been 
registered  in  the  brain  tissue.  Those  are  represented  to  the 
altered  consciousness  in  quick  succession  by  chance,  not  real 
association.  A  careful  study  will  often  succeed  in  discovering 
the  association  of  even  the  most  apparently  incoherent  ideas. 
The  ideas  have  had  some  former  connection  in  the  conscious- 
ness of  the  patient.  They  come  with  great  vividness,  so  that 
memories — representations — are  taken  for  actual  presentations 
to  the  senses,  I  had  a  maniacal  patient  who  had  kept  dogs, 
and  their  mental  images  were  evidently  as  strong  as  the  real 
sight  of  the  animals  before  his  eyes  had  ever  been.     He  called 

^  Journal  of  Mental  Science,  August  1875,  "Some  Organic  Laws  of 
Personal  and  Ancestral  Memory." 


164  STATES   OF   MENTAL   EXALTATION. 

them  by  their  names,  pointing  to  where  they  stood,  talked  to 
them  and  heard  them  barking.  His  reasoning  power  being 
perverted,  he  could  not  correct  those  impressions,  and  he 
believed  the  cerebral  images  of  his  former  presentations  to 
be  present  realities.  We  may  either  suppose  that,  through 
morbid  activity  in  the  nutrition  and  energising  of  the  centres 
of  sensation,  those  molecular  changes  which  each  previous 
perception  had  left  are  rendered  more  vivid  and  more  hke  the 
original,  as  when  a  photograph  by  the  stereoscope  is  made  to 
look  real  and  solid,  or  that,  through  failure  in  the  comparing 
and  judging  power  of  the  brain,  those  faint  images,  which  we 
in  health  call  memories,  are  actually  mistaken  for  real  percep- 
tions of  real  impressions  on  the  senses,  just  as  when  in  a  dim 
light  and  dreamy  humour  the  pictures  on  the  wall  stand  out 
as  real  men  and  women.  In  insanity  those  false  beliefs  in 
sense  impressions  are  called  Hallucinations,  to  distinguish 
them  from  insane  delusions,  which  are  false  beliefs  of  a  more 
abstract  kind.  //  a  man  of  fifty  believes  that  he  fought  at 
Trafalgar,  it  is  a  Delusion  ;  if  he  believes  that  he  sees  before  him 
Nelson  looking  through  his  glass,  that  is  a  Hallucination. 
There  is  a  false  belief  affecting  sense  impressions,  to  which  the 
term  Hlusion  has  been  applied  by  some  authors,  but  this  term 
will  have  to  be  given  up  in  this  sense  now  that  Mr  Sully  has 
written  his  book  on  Illusions  used  in  a  different  meaning.^ 
In  the  sense  I  refer  to,  if  the  person  really  saw  a  man  before 
Mm  and  said  that  he  was  Nelson,  it  luould  have  been  an 
Illusion, — there  being  a  real  sense  impression,  but  this  being 
misinterpreted  into  something  quite  different  from  what  it  really 
was.  Certain  cases  of  acute  mania  are  greatly  characterised 
by  the  prevalence  of  hallucinations  of  different  senses.  All 
those  symptoms  most  of  us  now  believe  to  be  in  some  measure 
explained  by  the  theory  of  the  morbid  excitation  of  Ferrier's 
and  Hitzig's  localised  centres  in  the  cortex  of  the  brain,  those 
centres  where  the  impressions  from  the  senses  are  received, 
and  where  co-ordinated  motions  arise.  As  further  progress 
1  Illusions,  by  James  Sully. 


STATES   OF   MENTAL  EXALTATION.  165 

in  brain  physiology  is  made,  no  doubt  we  shall  be  able  to 
localise  in  the  brain  the  causes  of  perverted  mentalisation  of 
different  kinds. 

As  illustrating  extreme  incoherence,  I  give  a  small  bit  of  a 
"  letter  "  of  twenty  pages,  containing  a  string  of  14,000  words, 
almost  all  adjectives  and  nouns,  with  no  more  connection  or 
aim  than  those  in  this  specimen : — "  Mediterranean,  horses, 
anathematised,  Athanasius,  propagated,  emphatic,  monasteries, 
diocese,  Egypt,  hermit,  biographer,  abuse,  furor,  fury,  medium, 
policies,  police,  hobby,  sacred,  phrase,  administration,  minis- 
terial, monasticism, counsel,    conviction,    revelation, 

moderate,  junior,  transact,  absurd,  disinherit,  repudiate, 
maternal,  instinct,  claimant,  reiterate,  clever,  rumour, 
demurred,  finesse,  illusion,  abstruse."  Now  you  see  that  there 
is  a  sort  of  association  of  ideas  between  a  great  number  of 
those  words,  and  you  can  imagine  how  one  arising  before  the 
mental  vision  would  suggest  the  one  next  it.  Here  is  another 
letter,  from  C.  K.,  of  a  more  usual  kind  of  half  incoherence  : 
— "Dear  Durham's  Allah,  You  will  please  see  that  Eliza  and 
Bella  are  out.  Mr  Swan  (his  attendant)  is  to  give  you  this  in 
a  few  minutes.  Compts.  to  Victoria  and  my  mother  Queen 
Elizabeth.  I  am  putting  '  John  '  before  John  Addison,  as  I 
think  him.  entitled  to  it.  No  kilts  my  bonnie  Durham.  My 
'  charm  of  life.'  More  than  India's  goods  to  me.  Blessing 
on  my  bonnie  wife.  I  will  love  you  till  the  day  I  die. 
Compts.  to  Louise  and  darling  Beatrice,  Jane  Shore,  and 
Elizabeth.     Come  into  the  garden,  Maud, 


"  The  tear  fell  gently  from  her  eye, 
When  last  we  parted  on  the  shore, 
My  bosom  heaves  with  many  a  sigh, 
To  think  I  ne'er  should  see  her  more. 


'  "Weep  not,  my  love,'  I  trembling  said, 
'  Doubt  not  a  constant  heart  like  mine  ; 

I  ne'er  can  find  a  prettier  maid, 

Whose  charms  can  fill  this  heart  of  mine.' 


166  STATES   OF   ISIENTAL   EXALTATION. 

'  Go  then,'  she  said,  '  and  let  thy  constant  mind 
Oft  think  of  her  you  leave  in  tears  behind  ;' 

'  Dear  maid,  my  heart's  embrace  my  wish  shall  be. 
The  anchor's  weighed  !  The  anchor's  weighed  ! 

Remember  me.'" 

There  is  no  difficulty  in  seeing  the  association  of  ideas,  or 
the  verbal  or  alliterative  suggestions  running  through  this 
"incoherence."  A  rhyming  speech,  a  poetical  way  of  putting 
things,  a  misquotation  of  poetry,  can  all  be  seen  in  the  above 
letter. 

The  affective  condition  in  this,  as  in  every  variety  of  mania, 
is  one  of  perversion  or  paralysis.  "We  would  describe  the  con- 
dition in  most  instances  by  saying  that  those  dearest  to  a  man 
are  most  disliked,  those  most  trusted  are  the  objects  of 
suspicion,  those  most  intimately  associated  with  the  patient 
are  most  shunned.  It  is  this  which,  more  than  anything  else, 
makes  its  occurrence  such  a  terrible  calamity.  Conjugal  affec- 
tion is  most  and  first  apt  to  give  way  ;  and  it  is  a  very 
common  fact  that  where  we  have  prolonged  and  incurable 
insanity  the  conjugal  affection  of  the  sane  husband  or  wife,  in 
most  instances,  ceases  long  before  the  maternal  or  sisterly 
affection  of  the  sane  blood  relations.  A  shrewd  old  Morning- 
side  head  attendant,  of  an  observant  if  somewhat  cynical  turn 
of  mind,  was  the  first  to  point  this  out  to  me  in  regard  to  those 
who  came  to  visit  the  chronic  patients  in  the  Asylum.  He 
said  he  noticed  that  wives  and  husbands  were  the  first  to 
diminish  the  frequency  of  their  visits,  and  soon  came  very 
seldom,  then  brothers  and  sisters,  then  fathers,  and,  last  of 
all,  mothers  and  old  aunts,  who  never  ceased  to  come,  how- 
ever uninteresting  the  patient  might  be,  however  long  he  was 
insane  !  Xo  rebuffs  from  the  patient  would  discourage  them ; 
no  want  of  reciprocity  would  cool  their  love  and  interest, 
which  never  failed.  I  commend  this  observation  to  students 
of  the  affections. 

The  actions  of  patients  labouring  under  acute  mania  differ 
as  much  as  their  speech.     They  can  all  be  referred  to  the 


STATES   OF    MENTAL   EXALTATION.  167 

morbid  excitation  of  the  motor  and  the  ideo-motor  centres  in 
the  brain.  One  man  is  simply  restless,  another  shouts, 
another  sings,  another  rushes  about  wUdly,  another  attacks 
those  near  him,  this  being  usually  the  result  of  delusions 
that  they  are  going  to  injure  him.  Some  violence  on  slight 
or  merely  imaginary  provocation  towards  those  nearest  and 
dearest  to  them  is  common.  In  Plate  III.  (the  facsimile  of  a 
patient's  letter)  there  is  seen  incoherence,  rapid  change  of 
ideas,  and  hallucinations  of  sight.  Sometimes  the  patient 
would  injure  himself  in  his  wild  fury  by  dashing  himself 
against  walls,  through  windows,  &c.  But  it  is  surprising  how 
much  more  rarely  than  is  usually  supposed  maniacal  patients 
are  really  or  to  any  extent  very  dangerous,  either  to  them- 
selves or  others.  In  this  matter  old  opinion  and  prejudices, 
the  fact  that  a  few  patients  are  dangerous,  or  that  a  dangerous 
stage  occurs  in  some  few  cases,  have  given  a  wrong  general 
impression,  and  done  very  much  harm  in  the  treatment  of 
acute  mania.  But  we  are  slowly  getting  over  this,  for  now 
we  endeavour  to  assume  that  any  patient  labouring  under 
this  disease  is  not  dangerous  till  he  is  proved  to  be  so,  instead 
of  the  opposite  old  maxim  that  he  was  to  be  regarded  as 
dangerous  till  he  proved  himself  to  be  safe ;  which  had  this 
unfortunate  result,  that  the  restraints  and  restrictions  and 
supposed  safeguards  imposed  on  him  so  irritated  him  that, 
if  he  was  not  dangerous  at  first,  he  was  probably  made  so  by 
them.  1^0  safe  outlet  was  provided  for  his  morbid  motor 
energy,  so  that,  Kke  all  pent-up  force  finding  no  outlet,  it 
became  dangerous  and  often  killed  the  patient. 

The  motions  and  gesticulations  of  an  acutely  maniacal 
patient  are  often  in  an  exact  degree  the  muscular  equivalents 
of  the  ideas  and  emotions  passing  through  his  brain,  just  as 
they  are  in  the  case  of  a  savage  or  a  born  orator  when  he 
makes  a  speech  about  a  subject  which  excites  him.  The  most 
awkward  of  men  often  becomes  easy  in  his  motions  when 
maniacal.  The  expression  of  the  face  is  always  changed,  and 
also  the  appearance  and  expression  of  the  eyes.     Usually  the 


168  STATES   OF   MENTAL   EXALTATION. 

man  is  so  changed  that  he  looks  "a  different"  man.  He  is 
always  worn-looking,  and  this  is  more  particularly  the  case  in 
the  female  sex.  There  is  no  natural  beauty  of  face  that  will 
persist  during  acute  mania.  Commonly  the  face  is  flushed, 
the  skin  muddy  and  less  delicate  in  tint  and  texture,  the 
features  unpleasant  to  look  on.  As  might  be  expected,  the 
infinitely  delicate  co-ordinations  and  fixations  of  the  small 
muscular  strands  that  in  the  face  mirror  forth  and  express 
the  mental  and  emotional  states  are,  in  this  disease,  inhar- 
monious, and  express  instead  inco-ordinated  mental  acts. 
In  this  disease,  and  in  insanity  generally,  the  expression  of 
the  face  closely  follows  the  mental  disturbances.  "We  may 
have  exaggerated  expression,  diminished  expression,  asym- 
metrical conditions,  partial  or  complete  paralysis  of  the 
muscles  of  expression,  and  every  degree  and  kind  of 
dissolution  of  facial  expression.  Dr  John  Turner  has  given 
us  a  very  careful  study  of  this  subject,  which  admits  of  still 
further  elucidation.^  The  eyes  are  more  especially  charac- 
teristic. They  usually  glisten  somewhat  as  in  fever;  the 
eyelids  are  more  widely  dilated,  so  that  the  white  is  seen 
round  the  cornea ;  and  their  expression  is  that  of  excitement 
and  turmoil. 

Bodily  Sijmptoms. — The  whole  digestive  tract  is  afi'ected 
more  or  less.  The  secretions  of  the  mouth  and  the  sahva 
are  altered  in  character,  and  when  inoculated  produce  a 
septic  or  irritating  influence.  The  sores  resulting  from  a  bite 
of  such  a  patient  are  apt  to  be  angry,  the  inflammation 
running  up  the  lymphatics.  The  most  recent  investigations 
show  the  septic  character  of  the  sahva.  The  tongue  is 
usually  furred,  and  the  breath  foul.  "^Tien  the  condition 
becomes  dehrious  there  is  always  a  tendency  to  have  a  dry 
mouth  and  tongue,  with  sordes  on  the  teeth.  The  appetite 
for  food  is  usually  paralysed,  though  not  always  that  for 
drink.     The  digestion  is  often  vigorous  enough,  though  not 

^  "  Asymmetrical  Conditions  met  with  in  the  Faces  of  the  Insane,"  &c. 
By  John  Turner,  M.B.,  Jour,  Menl.  Sci.,  Jan.  and  April  1892. 


STATES   OF   MENTAL   EXALTATION.  169 

in  the  exhausted  stage,  I  have  found  the  stomach  full  of 
undigested  food  in  patients  who  had  died  of  exhaustion  from 
acute  mania.  The  bowels  tend  to  be  costive,  though  this  is 
not  always  so.  The  temperature  is  usually  from  one  to  two 
degrees  above  the  normal,  especially  the  evening  temperature. 
As  we  shall  see,  it  runs  far  above  this  sometimes ;  but  if  it . 
rise  much  above  100°  we  look  out  for  a  febrile  or  inflam- 
matory cause,  or  for  general  paralysis,  or  other  organic  disease. 
The  skin  is  usually  clammy  and  ill-smelling,  though  sometimes 
harsh  and  dry.  In  women  the  menstrual  function  is  almost 
always  interfered  with,  being  usually  stopped  after  the 
excitement  has  continued  for  a  few  weeks.  The  odour  from 
a  woman  both  menstruating  and  maniacal  is  most  offensive. 
I  find  that  out  of  the  last  fifty  women  admitted  to  the 
Asylum  labouring  under  acute  mania,  three-fourths  had 
irregular  menstruation,  and  in  most  it  ceased  till  they  became 
convalescent  or  demented.  The  common  sensibility  is  much 
diminished  in  such  cases,  patients  not  feeling  pain  acutely, 
some  not  feeling  it  at  all.  Injuries,  cuts,  boils,  whitlows,  and 
such  painful  affections  are  borne  without  much  complaint  of 
pain.  With  their  feet  inflamed  they  will  walk,  with  their 
hands  bruised  and  sore  they  will  use  them  freely. 

The  continuance  of  this  condition  is,  of  course,  attended 
Avith  rapid  and  great  loss  of  body  weight.  I  have  known  a 
patient  lose  a  stone  of  flesh  in  a  week,  notwithstanding  that 
he  was  getting  plenty  of  food.  But  after  losing  any 
redundancy  of  fat  it  commonly  happens  that  the  intensity 
of  the  disease  diminishes  and  the  loss  of  weight  is  less  rapid. 
It  usually  takes  a  considerable  time,  always  provided  a 
sufficient  quantity  of  proper  food  is  given,  and  proper  treat- 
ment adopted,  before  extreme  emaciation  and  weakness 
result.  The  more  intense  the  attack  the  shorter  is  usually 
its  duration ;  in  fact,  a  great  prolongation  of  very  acute 
dehrious  mania,  with  a  temperature  of  over  100°,  no  sleep, 
and  constant  violent  motor  excitement,  is  dangerous  to  life. 
Few  cases  die  in  the  first  week  of  the  attack ;  some  do  in  the 


170  STATES   OF   MENTAL   EXALTATION. 

first  fortnight,  and  some  in  the  first  month.  In  a  subacute 
form  it  is  wonderful  how  long  it  may  last,  without  producing 
fatal  results,  or  even  reducing  the  patient  very  much,  if  he 
eats  enough — and  enough  may  mean  four  times  his  usual 
amount  of  food — and  is  sufficiently  in  the  fresh  air,  and  is 
not  restrained  in  his  movements. 

Restraint  v.  Non-Restraint. — In  by  far  the  majority  of 
instances  such  mechanical  restraint  as  used  to  be  employed 
in  this  country,  and  is  still  employed  in  many  places  elsewhere, 
— by  strait-jackets,  camisoles,  gloves,  straps,  &c., — cause  such 
a  feeling  of  degradation,  irritation,  and  resistiveness,  that  the 
good  effects  of  any  actual  conservation  of  force  by  such 
restraint  is  in  my  opinion  far  more  than  counterbalanced. 
The  disease,  if  it  does  not  kill,  is  more  apt  under  such  treat- 
ment to  run  on  into  chronic  mania  and  dementia.  To 
restrain  the  mere  outward  muscular  movements,  while  the 
motor  energy  is  all  the  while  being  generated  in  the  brain 
convolutions,  is  eminently  unphysiological.  .Almost  as  well 
restrain  the  movements  of  the  choreic  or  the  convulsions  of 
the  tetanic  patient  by  binding  them  tightly  and  expect  a  good 
result.  Our  great  efforts  in  the  treatment  of  such  cases  now 
is  to  find  suitable  outlets  for  the  morbid  motor  energy,  to 
turn  the  restless,  purposeless  movements  into  natural  channels, 
to  get  the  patients  to  dig  and  wheel  barrows  soon,  and 
to  walk  long  distances,  instead  of  shouting  and  gesticu- 
lating. We  find  that  this  saps  and  exhausts  the  morbid 
energy  and  excitement,  producing  healthy  exhaustion  and 
sound  sleep,  vigorous  digestion,  and  due  excitation  of  the 
skin,  the  glands,  and  the  excretory  apparatus  generally. 
This  is  the  chief  physiology  and  philosophy  of  the  modern 
British  "  non-restraint "  treatment  of  mental  diseases.  Ko 
doubt  there  are  exceptions  to  all  rules.  I  have  seen  cases 
where  restraint  had  to  be  applied  to  prevent  the  patient 
exhausting  or  hurting  himself,  and  I  have  had  two  or  three 
patients  die  suddenly  from  exhaustion,  one  of  them  "  dropping 
down "  after  long  walking,  but  they  are  amazingly  few  in  a 


STATES  OF  MENTAL  EXALTATION.  171 

well-equipped  asylum,  with  large  grounds,  a  farm,  good 
attendants,  and  plenty  of  them,  and  a  padded  room.  Under 
those  circumstances  not  one  case  in  a  thousand  is  found  to 
need  restraint.  But  it  is  quite  diiferent  when  we  have  to 
treat  a  patient  in  a  private  house,  or  with  insufficient 
attendance.  Then  mechanical  restraint  may  be  unavoid- 
able. It  often  happens  that,  at  the  commencement  of  a 
case,  where  the  symptoms  have  developed  rapidly  into  an 
acute  form,  you  may  think  it  advisable  to  give  the  patient 
a  chance  of  its  soon  passing  off,  or  arrangements  cannot 
be  at  once  made  for  removal  to  an  asylum  through  the 
absence  of  those  who  can  authorise  it,  or  the  relations  of  the 
patient  may  absolutely  insist  on  his  being  treated  out  of 
an  asylum.  In  these  circumstances  you  have  to  do  the  best 
you  can  with  the  means  at  your  disposal,  carrying  out  to 
as  great  an  extent  as  you  can  the  principle  of  providing  an 
outlet  in  the  open  air  for  the  morbid  motor  energy  that  is 
being  generated  in  the  brain  convolutions,  but  using,  it  may 
be,  restraint  to  some  extent. 

Stages. — Acute  mania  is  in  some  cases  divided  into  three 
stages :  the  first  that  which  I  have  described  as  simple 
mania,  the  second  that  of  ordinary  acute  mania,  and  the 
third  that  of  dehrious  mania,  with  a  tendency  to  dry  tongue, 
&c.  But  a  case  may  be  one  of  acute  delirious  mania  from 
the  beginning.  The  aggravated  and  fatal  cases  of  this  form 
were  described  by  Dr  Luther  Bell  as  typho-mania.  We 
seldom  see  such  cases  here. 

Pathological  Risks. — As  you  can  readily  understand,  from 
the  delicate  constitution  of  the  grey  brain  substance — that 
highest  evolution  in  nature  of  function  and  structure — and 
the  infinite  complexity  of  its  balanced  and  interdependent 
functions,  the  continuance  of  such  an  abnormal  brain-storm 
as  that  which  exists  in  acute  mania  may  be  followed  by 
permanent  and  irretrievable  damage.  Such  a  storm,  be- 
sides aU  the  bodily  symptoms  and  disturbances  which  I 
have  described,  is   accompanied  by  intense   congestion  and 


172  STATES  OF  MENTAL  EXALTATION. 

over-action  in  the  grey  nenrine  and  brain  generally,  the 
congestion  being  -usually  seen  in  limited  areas  (see  Plate  IV.), 
those  probably  tending  soon  to  pass  into  structural  changes. 
The  cells  tend  to  get  granular,  there  is  a  proliferation  and 
enlargement  of  the  nuclei  of  the  neurogha,  the  lymphatic 
spaces  and  perivascular  canals  get  over-dilated  and  blocked 
up  with  debris,  and  an  enormous  number  of  microscopic 
capillary  extravasations  may  take  place  in  and  around  the 
convolutions  in  bad  cases.  Some  writers  speak  as  if  the 
cortical  hypersemia  constituted  the  disease,  and  that  treatment 
should  be  chiefly  directed  towards  diminishing  the  blood  in 
the  capillary  vessels,  Krafft-Ebing  recommending  leeches  to 
the  head,  and  others  enforced  "rest"  and  absence  of  sensory 
stimuli  for  that  purpose.  ISTothing  can  be  more  unphilo- 
sophical,  it  seems  to  me,  than  such  propositions  generally 
appHed.  What  Ave  want  is  to  alter  the  mode  of  energising 
of  the  cells,  so  that,  instead  of  being  explosive  and  morbid, 
it  may  become  normal.  The  capillary  congestion  is  a  secondary 
matter,  and  will  soon  come  right  in  most  cases  when  the 
cells  cease  to  make  extraordinary  calls  for  an  undue  amount 
of  blood.  The  vessels  may  get  thickened  in  their  coats  and 
tortuous,  the  fibrous  matter  of  the  pia  mater  becomes  hyper- 
trophied,  the  arachnoid  milky,  the  dura  mater  thickened  or 
adherent  to  the  bone,  and  the  bony  case  dense  and  thickened. 
All  those  things  may  happen  through  prolongation  of  the  acute 
symptoms.  Therefore  it  is  of  the  last  importance  to  shorten, 
if  we  can,  the  acute  stage.  Every  week  of  this  adds  to  the 
chances  of  the  acutely  excited  state  being  followed  by  more 
or  less  permanent  mental  defect.  Even  the  present  risk  to 
life  is  not  so  grave  a  risk  as  that;  for  which  of  us,  if  we 
had  the  choice,  would  not  prefer,  on  the  whole,  death  to  a 
degradation  from  our  mental  and  emotional  eminence  in 
creation  to  a  state  of  permanent  mindlessness,  in  which 
we  would  be  dead  to  the  love  and  hatred  and  to  the  joys 
and  pains  of  life,  oblivious  of  the  past  and  unconcerned  for 
the  future,  stirred  by  no  ambition,  capable  of  no  effort,  and 


STATES   OF   MENTAL   EXALTATION.  173 

unmoved  by  any  motive  ?  For  such  is  the  dementia,  of 
which  I  am  to  speak  afterwards,  that  sometimes  follows 
and  results  from  mania.  My  experience  has  been  that  60 
per  cent,  of  the  cases  of  acute  mania  recover,  7i  per  cent, 
die,  and  32|  per  cent,  become  demented  or  pass  into  chronic 
mania.  There  is,  perhaps,  more  opportxmity  for  right  treat- 
ment and  management  in  acute  mania  than  in  any  other 
kind  of  mental  disease. 

General  Indications  for  the  Treatment  of  Acute  Mania. — 
In  the  beginning  of  the  attack,  and  sometimes,  when  the 
patient  is  wealthy,  all  through  it,  we  have  to  treat  the 
case  at  home.  Now,  no  doubt,  the  first  thing  to  be  done 
is  to  get  proper  trained  attendants  —  one,  two,  three,  or 
even  four,  may  be  necessary  for  night  and  day  work.  Patient, 
sensible,  experienced,  cool,  and  kindly  men  and  women  are 
what  we  want.  Then  proper  arrangements  must  be  made, 
— a  good  suite  of  two  large  rooms  on  the  ground  floor  of 
a  house,  with  a  garden,  and  not  too  near  a  public  road, 
being  required.  Small  breakable  articles  must  be  removed, 
but  do  not  make  the  rooms  quite  desolate  or  unattractive- 
looking.  Fasten  windows  not  to  open  more  than  five  or 
six  inches,  and  see  that  no  knives  or  lethal  weapons  are 
too  handy.  But  do  not  do  all  this  demonstratively  to  attract 
the  patient's  attention.  Next,  you  must  look  to  the  feeding 
with  suitable  nutriment  very  often ;  sometimes  you  can  give 
it  only  little  and  often,  sometimes  in  ordinary  meals,  with 
beef-tea  and  milk  in  between.  Milk,  eggs,  beef-tea,  ground 
beef,  custards,  strong  soups  with  plenty  of  vegetables,  and 
porridge,  are  the  best,  as  often  as  the  patient  can  be  got 
to  take  them,  and  in  as  large  quantity.  As  Dr  Blandford 
says,  "  We  can  hardly  give  too  much."  Do  not  for  a 
moment  be  afraid  of  a  dirty  tongue,  and  think  it  contra- 
indicates  food.  Nothing  could  be  a  greater  mistake,  in 
acute  mania  at  all  events.  The  furred  tongue  is  not  from 
an  overloaded  alimentary  canal,  but  results  from  perverted 
innervation  of   the  digestive   tract.      Malt  liquors,  such  as 


174  STATES   OF   MENTAL  EXALTATION. 

porter  and  ale,  can  be  given  freely  with,  advantage.  Good 
wines,  too,  if  they  can  be  got.  Even  whisky  or  brandy 
will  act  as  a  direct  sedative  to  the  excitement  in  some 
cases.  Anstie  taught  us  some  good  therapeutics,  in  his 
Stimulants  and  Narcotics,  on  this  point.  But  alcohol,  you 
will  find,  will  sometimes  flush  and  cause  excitement.  In 
that  case  use  it  sparingly.  I  have  seen  a  pint  of  beef-tea, 
representing  all  that  was  soluble  in  a  pound  of  beef-steak, 
and  a  glass  of  whisky,  reduce  the  temperature  2*3°.  To  show 
the  quantity  of  food  that  such  patients  can  take  and  digest, 
I  mention  that  at  the  Asylum  I  am  never  satisfied  except  the 
bad  cases  get  at  least  six  eggs  a  day  beaten  up  in  Kquid  custards, 
in  addition  to  their  ordinary  food,  beef -tea,  up  to  convalescence. 
I  have  known  many  patients  take  a  dozen  eggs  a  day  for 
three  months  running.  The  constant  motion  and  fresh  air 
enable  them  to  digest  and  assimilate  most  of  this.  So  long  as  a 
patient  is  losing  weight,  the  physician  should  never  be  satisfied. 
When  he  becomes  stationary,  then  one  may  begin  to  think 
that  the  disease  is  being  overcome  by  nature  and  treatment. 
When  he  begins  to  gain  in  weight,  and  the  temperature 
becomes  normal,  then  convalescence  or  dementia  has  begun. 
The  patient  should  be  weighed  every  week  during  the  acute 
stage. 

]N"ext  to  good  food  and  nursing,  fresh  air  is  most  essential 
to  treating  a  case.  No  patient  must,  on  any  account,  or  in 
any  weather,  except  he  is  excessively  run  down  or  exhausted 
indeed,  be  kept  in  bed  or  in  the  house  for  many  days. 
Herein  is  the  essential  difference  between  the  treatment  of 
this  disease  and  that  of  acute  bodily  complaints.  I  often 
keep  patients  out  all  day  in  the  summer  time.  When  they 
are  recovering  they  all  say  that  they  feel  better  out  than  in. 
There  is  no  soporific,  no  calmative,  and  no  digestive  like  the 
fresh  air.  And  the  attendants  must  not  restrain  or  interfere 
more  than  is  necessary.  There  should  be  no  nagging  and 
small  interferences,  and  little  arguing,  but  a  kindly,  firm 
mode  of  deahng  with  a  patient — coaxing,  when  coaxing  will 


STATES   OF   MENTAL   EXALTATION.  175 

do,  and  firm  insistance,  and  force  sufficient  to  overcome 
resistance  when  necessary.  There  is  a  certain  kind  of  tact 
which  some  people  have,  and  which  may  be  partly  acquired, 
but  which  is  mostly  a  natural  gift,  and,  when  present,  is  of 
the  greatest  avail  in  overcoming  resistance,  persuading  patients 
to  take  food,  &c.  Women  have  it  more  frequently  than  men, 
and  women  will  often  persuade  male  patients  when  their  own 
sex  fails.  It  does  not  do  to  let  patients  have  too  much  of 
their  own  way.  A  happy  mean  between  that  and  too  much 
interference  should  be  pursued.  It  is  better  to  be  honest, 
and  not  deceive  patients  into  doing  things.  That  often  makes 
them  lose  confidence,  and  does  harm  afterwards.  Medicine 
when  given  should,  as  a  general  rule,  be  given  as  medicine, 
and  not  be  put  in  food  surreptitiously.  The  safety  of  the 
patient  and  those  about  him  must  of  course  be  provided  for. 

For  the  bowels  it  is  sometimes  necessary  at  first  to  use 
laxatives  and  enemata,  and  even  strong  purgatives,  such  as 
croton  oil,  but  I  try  first  such  mild  medicines  as  castor  oil, 
Tamar  Indien  lozenge,  liquorice  powder,  warm  water  enemata, 
&c.  Do  not  insist  on  a  stool  every  day ;  one  every  second 
or  third  day  is  quite  enough.  Depleting  remedies  of  all  sorts 
are  in  my  opinion  bad. 

There  is  one  remedy  tharfc  I  have  seen  do  good  in  many 
cases,  and  in  a  few  act  like  a  charm,  and  that  is  prolonged 
warm  baths  with  cold  to  the  head.  The  effect  of  this  is  to 
fill  the  capillaries  all  through  the  body,  and  to  withdraw 
blood  from  the  brain,  to  depress  the  heart's  action — and 
hence  its  danger — to  soothe  the  nervous  irritation,  and  to 
produce  sleep.  I  have  the  highest  opinion  of  its  efficacy, 
but  unfortunately  it  is  attended  with  danger  in  some  cases. 
A  man,  whom  I  could  not  detect  to  have  heart  disease,  once 
died  in  my  hands,  as  it  were,  when  I  was  sitting  beside  him, 
after  being  less  than  an  hour  in  water  at  103°.  I  know  of 
two  other  cases  where  syncope  and  death  resulted  in  the 
same  way.  I  used  to  keep  the  water  up  to  110°,  but  I  never 
do  so  now.     In  fact,  I  now  prefer  99°  as  the  proper  tempera- 


176  STATES   OF   MENTAL   EXALTATION. 

ture.  But  tlie  effect  with  this  is  not  so  quick  nor  so  marked. 
Baillarger  used  to  keep  his  patients  steeping  for  days  in 
water  at  96°  or  98°.  I  do  not  think,  however,  the  treatment 
is  so  much  in  vogue  now  in  Paris  as  it  was  twenty  years  ago. 
Dr  Rees  Philipps  has  taken  to  the  use  of  the  very  prolonged 
tepid  bath  at  the  Sanatorium,  Yirginia  "Water,  and  speaks 
enthusiastically  as  to  the  good  results.  Shower  baths  of  a 
mild  kind  are  sometimes  useful  when  the  mania  threatens  to 
become  chronic,  or  when  the  earher  symptoms  of  dementia 
show  themselves,  and  the  patient  is  strong  and  can  react 
after  the  bath.  The  great  trouble  is  that  patients  are  apt 
to  look  on  the  shower  bath  in  any  form  as  a  punishment, 
and  so  its  use  may  have  a  bad  moral  effect  on  them. 

Sedatives  and  Hypnotics  in  Mania. — One  difficulty  in  treat- 
ment is  to  use  narcotics  and  hypnotics  rightly.  The  greatest 
differences  of  opinion  have  existed,  and  do  prevail  at  present, 
about  them.  "What  we  want  and  have  not  yet  got  is  a 
medicine  that  will  cause  really  natiiral,  restful,  refresliuig 
sleep,  and  one  that  will  stay  or  slacken  the  morbid  energising 
of  the  brain  cells  in  the  convolutions  without  aflfecting  the 
appetite  or  the  nutrition.  That,  however,  is  not  known  to 
us  in  a  perfect  form.  All  medicines  that  markedly  lessen 
the  appetite  or  impair  the  digestion  or  nutrition  I  condemn 
in  this  disease.  In  ninety-nine  cases  out  of  a  hundred  opium 
does  this,  more  or  less,  and  should  not  be  employed  except 
as  a  mere  temporary  placebo  or  for  a  special  purpose.  My 
experiments  with  it,  and  practical  experience  of  it  is,  that  it 
has  those  objectionable  effects  in  most  cases  where  given. 
Chloral  we  all  believed  in  and  used  very  extensively  in  mania 
after  its  discovery.  It  seemed  a  perfect  sleep-producer. 
Numbers  of  cases  have  I  kept  under  its  influence  day  and 
night  for  weeks,  and  many  of  them  certainly  got  well.  But 
I  do  not  beheve  so  much  in  it  now.  Its  sleep  is  sound  and 
seems  natural,  but  somehow  is  not  refreshing  Kke  nature's 
sleep.  I  am  inchned  to  think  that  an  hour  or  two's  sleep 
naturally  after  a  day's  exercise  in  the  open  air  is  more  than 


STATES   OF  MENTAL   EXALTATION.  177 

equal  to  eight  hourf?'  drug  sleep.  My  experience  is  that  it 
has  a  subtle  influence  for  harm  on  the  brain  when  much 
given,  by  which  the  organ  loses  that  quality  which  we  call 
tone.  The  patients  cannot  bear  pain  so  well.  They  have- 
not  the  resistive  pov/er,  and  they  are  apt  to  look  pale  and 
unrefreshed  in  the  morning.  Besides  this,  I  had  two  patients 
who  died  suddenly,  each  of  them  during  a  sudden  gust  of 
excitement,  when  under  the  influence  of  moderate  doses  of 
30  grains ;  in  both  of  them  I  found  the  blood  dark  and 
fluid,  and  the  right  side  of  the  heart  and  the  lungs  engorged, 
as  if  there  had  been  a  sudden  paralysis  of  the  breathing 
centre  in  the  pons.  I  could  not  certainly  say  that  the  chloral 
caused  their  deaths^  One  had  decided  brain  disease,  and 
sudden  deaths  do  occur  in  acute  mania  when  no  medicine  has 
been  given,  through,  as  I  believe,  epileptiform  conditions 
causing  paralysis  of  the  breathing  centre.  I  have  never 
given  chloral  as  a  sedative  during  the  day  since.  ISTow  I 
give  it  at  night,  or  after,  or  during  convulsions,  and  always 
in  small  doses  of  from  10  to  25  grains,  with  from  half  a 
drachm  to  a  drachm  of  bromide  of  potassium.  I  much 
prefer  paraldehyde  as  a  pure  hypnotic,  in  doses  of  from  40 
•  minims  up  to  four  drachms  or  even  more.  It  may  be  com- 
bined with  the  bromides.  It  is  an  almost  certain  producer 
of  sleep,  it  does  not  weaken  the  heart's  action,  it  leaves  few 
af ter-efi'ects,  and  it  is  in  my  experience  quite  safe.  Sulphonal 
I  look  on  as  being  on  the  whole- the  most  valuable  medicine 
of  the  kind  lately  discovered.  It  soothes,  it  causes  sleep,  its 
effects  will  often  last  for  forty-eight  hours,  and  in  some  few 
cases  it  makes  directly  for  restoration  and  sanity.  I  have 
now  had  so  many  cases  where  the  direct  arrestment  of  the 
maniacal  symptoms  by  this  drug  was  followed  by  immediate 
recovery,  without  any  tendency  to  recurrence,  that  I  am 
satisfied  of  its  directly  curative  influence.  If  its  use  is  pro- 
longed, the  dangerous  condition  of  haematoporphyrinuria  must 
be  looked  for  in  rare  cases.  Urethane  is  in  my  experience 
a  weak  and  uncertain  hypnotic,  except  in  very  mild  cases 

M 


178  STATES  OF  MENTAL  EXALTATION. 

indeed.  A  combination  that  I  have  found  most  useful  has 
been  the  bromide  of  potassium  and  tincture  of  cannabis  indica, 
with  which  I  have  made  careful  and  prolonged  experiments. 
It  soothes  during  the  day  and  sometimes  permanently  allays 
the  brain  excitation,  and  it  causes  sleep  at  night,  without 
diminishing  the  appetite  much  or  impairing  the  digestion, 
though  it  depresses  the  vascular  action.  I  have  used  the 
bromide  alone  in  acute  mania  extensively  and  experimentally. 
In  small  doses  it  seems  to  have  no  effect.  In  very  large  and 
continuous  doses,  say  a  drachm  every  three  hours  continued 
for  many  days,  it  will  cause  bromism,  and  quiet  the  patient, 
but  when  its  influence  is  over  he  becomes  as  bad  as  ever. 
Hyoscine,  in  doses  of  from  yig-  to  —  grains,  is  an  admirable 
quieter  of  motor  restlessness,  and  often  does  good.  Its  great 
merit  is  that  it  can  be  given  hypodermically.  I  have  seen 
nitrite  of  amyl  (a  drop  inhaled)  produce  calm  in  a  suddenly 
epileptiform  case  of  mania.  Morphia  and  hyoscine  may  be 
subcutaneously  injected  if  refused  by  the  mouth,  but  I  advise 
you  to  beware,  and  not  use  too  large  doses  in  this  way.  It 
may  be  justifiable  in  treating  cases  at  home-  to  tide  over 
severe  paroxysms  with  those  drugs,  and  sometimes  in  that 
way  to  keep  the  patient  out  of  an  asylum  as  long  as  possible. 
When  a  maniacal  patient  is  sent  to  the  Asylum,  I  now 
frequently  use  for  a  few  nights  small  doses  of  the  bromides, 
sulphonal  or  paraldehyde,  and  give  warm  baths ;  but  after  a 
fortnight,  when  I  see  that  the  attack  is  not  going  to  be  cut 
short  or  run  a  very  short  course,  I  am  more  apt  to  trust  to 
the  nursing,  diet,  and  conditioning  of  life  I  have  mentioned, 
with  contiinuous  tonics.  Conium  is  a  good  sedative  in  some 
cases,  and  tincture  of  lupuline,  in  the  milder  cases,  I  have 
known  to  produce  sleep.  Camphor  in  some  womeri  does 
much  good. 

Tonics. — I  now  ^ve  nearly  all  my  cases  quinine  from  the 
begioning,  adding  iron  in  some  cases  that  are  manifestly 
aneemic,  with  sometimes  the  phosphates  of  hme  and  soda. 
The  bitter  tonic  and  digestive  medicines  with  uitro-muriatic 


STATES  OF  MENTAL   EXALTATION.  179 

acid  I  use  largely  in  cases  that  run  on  for  long,  and  during 
convalescence.  Strychnine  is  most  useful  at  the  later  stages 
of  the  disease  where  there  is  a  tendency  to  stupor  and  brain 
torpor,  but  is  too  stimulating  at  first. 

After  Symptoms. — When  the  acute  symptoms  pass  off, 
especially  if  they  have  lasted  long,  there  is  apt  to  be  a  stage 
of  reaction,  attended,  in  some  cases,  with  complete  prostra- 
tion, in  others  with  depression,  in  others  with  an  apparent 
mental  enf eeblement  which  very  closely  resembles  dementia  ; 
in  fact,  it  is  a  stupor  of  a  transitory  kind.  You  must  on 
no  account  confuse  it  with  the  real  dementia,  for  while  the 
one  is  quite  amenable  to  treatment,  and  requires  treatment 
urgently,  the  other  is  an  incurable  brain  condition.  I  once 
showed  a  girl,  who  had  just  passed  through  a  prolonged 
attack  of  acute  mania,  and  who  was  stupid,  dirty  in  habits, 
and  seemed  demented,  as  a  typical  example  of  newly-begun 
dementia,  in  a  clinical  lecture,  and  pronounced  her  a  hope- 
lessly incurable  case ;  but  she  gradually  picked  up  in  flesh, 
got  enormously  fat,  her  brain  roused  itself  into  almost  its 
former  activity,  she  was  discharged  recovered,  and  remained 
well  for  nine  years.  The  treatment  for  this  stage  of  acute 
mania  is  tonic  and  nerve  stimulant,  stimulating  medically  and 
fattening  dietetically  (use  beef  and  animal  food  at  this  stage 
as  much  as  possible).  Eousing  and  occupation,  and  "  cheering 
up "  by  amusements,  &c.,  are  most  useful,  too,  as  brain 
stimulants  and  restorers.  Sometimes  patients  have  to  leave 
the  asylum  to  get  cured  of  this  result  of  mania.  Their  brains 
need  to  be  subjected  to  the  natural  stimuli  and  interests  of 
outside  natural  life.  There  is  a  process  of  re-education  of 
their  damaged  but  recuperable  brains  that  must  be  gone 
through.  They  are  in  the  state  of  a  joint  damaged  by  an 
acute  rheumatic  inflammation,  that  may  take  a  long  time  and 
much  exercise  and  friction  to  get  it  working  as  it  once  did. 
Unfortunately  certain  mental  peculiarities  remain  permanently 
in  many  cases. 

The  following  was  a  typical  case  of  acute  mania,  running 


180  STATES  OF  MENTAL   EXALTATION. 

through  its  three  stages  both  in  its  onset  and  as  it  passed  away. 
The  intensity  of  the  brain  storm  teas  so  great  at  its  acme  as 
almost  to  Mil  tlie  jpatient : — 

C.  L.,  set.  36.  Married.  Temperament  sanguine.  Diathesis 
nervous.  Disposition  cheerful,  frank,  and  exceedingly. enthu- 
siastic when  he  took  anything  up.  Habits  very  steady,  and 
almost  over-industrious,  for  after  his  work  was  done  he  would 
spend  all  his  evenings  in  doing  church  work.  Education 
fair.  Father  died  at  70  of  paralysis  5  brother  had  an  attack 
of  acute  mania  at  27  from  over  brain- work,  from  which  he 
recovered,  and  then  again  had  another  attack  and  died  in  it. 
Mother  had  an  attack  of  puerperal  mania  after  the  birth  of 
one  of  her  children,  and  her  maternal  grandfather  and  aunt 
were  insane.  This  is  the  first  attack,  and  has  assumed  an 
acute  form  for  three  days.  He  became  depressed,  reserved, 
and  altered  three  or  four  weeks  ago,  and  tliis  was  accompanied 
by  tliinness  and  sleeplessness.  Then  he  began  to  be  excited, 
elevated,  talkative,  and  restless,  and  quickly  passed  into  wild 
delirious  excitement,  which  had  existed  for  two  days  before 
admission.  He  was  very  dangerous  to  his  wife  and  children. 
He  had  taken  Kttle  food  for  two  days,  and  never  slept  during 
that  time,  though  he  seems  to  have  had  enormous  doses  of 
morphia.  On  admission  he  was  very  exalted,  singing  hymns, 
quoting  passages  of  Scripture,  and  swearing  in  the  same 
breath ;  shouting  and  raving.     His  excitement  was  intense. 

He  threw  himself  about  the  padded  room  into  which  we 
had  to  put  him.  It  took  four  or  five  strong  men  to  manage 
liim  safely,  though  he  was  a  small  man.  He  had  hallucina- 
tions of  sight  and  hearing.  He  .was  thin  and  sallow.  He 
was  covered  with  bruises,  and  one  rib  was  broken,,  all  got 
in  his  struggles  at  home.  His  tongue  was  clean  and  dry, 
bowels  costive,  appetite  gone.  Pulse  difficult  to  count,  on 
account  of  his  excitement.  Temperature  99°  on  admission, 
and  100'6°  at  night.  He  felt  no  pain.  He  would  put  his 
feet  up  on  the  walls,  with  his  head  down,  and  run  so  round 
the  room.    He  would  leap  up  and  then  fall  down.    He  would 


STATES   OF  MENTAL  EXALTATION.  181 

seize  those  near  to  him,  and  try  to  throttle  them,  thinking 
they  were  devils.  He  tore  his  blankets  and  bedding.  At 
times  he  would  be  quiet,  and  in  a  way  rational,  then  he 
would  get  maniacal  in  a  moment  without  warning  and  with- 
out outward  cause.  He  was  fed  regularly  with  custards  and 
sherry  by  force,  as  he  had  a  great  aversion  to  food,  saying  it 
was  poison.  Patients  who  are  maniacal  often  have  this 
delusion,  the  idea  being  suggested  to  them  by  their  own 
perversion  of  the  sense  of  taste.  I  have  no  doubt  that  all 
food  tastes  ill  to  them.  This  brain  condition  exhausted  him 
very  much,  so  that  I  feared  he  was  going  to  die.  He  got  twelve 
eggs  a  day  and  much  milk.  We  could  only  get  him  into  the 
fresh  air  for  a  short  time  each  day,  his  struggles  and  the 
risk  of  injuring  himself  being  so  great.  He  almost  never 
slept.  After  three  weeks  he  began  to  improve,  and  he  had 
lucid  intervals,  during  which  he  was  quiet.  He  had  several 
boils  on  his  arms  and  legs  at  the  time,  and  I  looked  on  this  as 
a  critical  event.  His  temperature  never  rose  so  high  after 
this,  his  appetite  returned,  and  we  were  able  to  give  him  solid 
food  in  a  mixed  form  for  the  first  time.  He  was  able  to 
walk  round  the  grounds  in  four  weeks,  being  then  talkative, 
lively,,  chaffing  everybody  he  met,  full  of  fleeting  delusions, 
especially  as  to  the  identity  of  those  near  him.  He  took 
most  violent  antipathies  to  his  attendants,  and  would  accuse 
them  of  quite  impossible  cruelties  to  him,  such  as  putting 
him  into  a  mill  and  breaking  every  bone  in  his  body,  so  that 
we  had  to  be  constantly  changing-  them  to  soothe  him.  He 
was  weak,  pale,  thin,  and  haggard,  but  said  he  felt  strong 
when  he  began  to  go  out  to  walk.  After  that  he  was  never 
in  the  house  except  at  night.  He  walked,  and  when  tired 
he  sat  or  lay  down  on  seats  in  the  grounds.  He  continued 
excited,  noisy,  singing,  and  very  exalted  in  feehng  during 
the  second  month  of  his  stay,  still  taking  his  twelve  eggs  a 
day,  in  addition  to  his  ordinary  diet  and  other  extras,  and  he 
gained  a  stone  the  second  month  of  his  residence..  He  had 
several   short  relapses  for  a  few  days.     In  two  and  a  half 


182  STATES   OF   MENTAL   EXALTATION. 

months  he  hegan  to  have  a  glimmering  consciousness  of  his 
position,  and  a  faint  return  of  natural  feeling.  His  first 
letter  to  his  wife  at  that  time  was  a  model  of  conciseness  : — 
"  Dear  Wife,  Where  are  you  ?  C.  L."  In  three  months  he 
was  in  the  condition  I  have  descrihed  as  typical  in  simple 
mania  —  gay,  humorous,  careless,  talkative,  hut  with  no 
delusions,  sleeping  well,  and  rapidly  gaining  in  weight  and 
strength.  He  was  during  this  time  getting  all  sorts  of  tonics — 
quinine,  iron,  phosphates,  cod-Uver  oil,  &c.  This  state  lasted 
other  three  months,  all  this  time  his  hrain  getting  more 
normal  in  its  working,  and  at  the  end  of  six  months  from  his 
admission  he  was  discharged  well  in  mind  and  stouter  than 
he  had  ever  been  in  his  life,  having  gained  two  stone  in 
weight  since  admission,  and  he  has  kept  well  and  done  his 
work  ever  since,  I  seldom  heheve  in  the  perfection  of  a 
recovery  from  acute  mania  unless  the  patient  is  fat ;  and 
when  he  is  so  I  always  think  liis  chances  of  not  having  a 
relapse  for  some  time  are  good.  I  like  a  gradual  steady 
recovery,  too,  not  perhaps  so  long  as  this,  rather  better  on 
the  whole  than  a  sudden  recovery. 

The  following  is  another  characteristic  case  of  acute  mania 
running  through  a  typical  course: — 

C.  L.  A.,  set.  47,  of  a  sanguine  temperament,  cheerful  and 
frank  disposition,  and  industrious  and  temperate  habits,  hut 
of  a  very  fiery  and  ungovernable  temper.  Tliis  was  her  first 
attack.  Her  mother  was  insane.  This  heredity  and  the 
nearness  of  the  cHmacteric  period  may  be  considered  as  the 
predisposing  causes,  while  the  exciting  cause  was  exhaustion 
from  want  of  sleep  and  mental  anxiety  in  nursing  her  mother 
on  her  death-bed.  The  first  mental  symptoms  occurred  about 
fourteen  days  before  admission,  in  the  shape  of  restlessness, 
unsettledness,  and  getting  up  in  the  middle  of  the  night  to 
wash.  For  four  days  she  had  been  worse,  seeing  visions, 
constantly  talking,  imagining  that  people  were  under  her  bed, 
and  never  sleeping.  On  admission  there  was  great  exaltation, 
incessant  and  almost  incoherent  talking,   much  excitement, 


STATES   OF   MENTAL  EXALTATION.  183 

walking   about,   gesticulation,    singing,    saying   she   saw  the 
"  heads   of   people "   about  her.     She  addressed  the  people 
about  her,  whom  she  had  never  seen  before,  as  her  friends, 
mistaking  their  identity,  making   sarcastical  remarks  about 
them — "  Oh  !  Kitty,  is  that  you  ?     That's  a  fine  gown  you 
have  on.     Wlio  gave  you  it  ?     Is  it  paid  for  1 "  &c,,  &c.     At 
times   she   was   quite   incoherent.     In   person   she  was  fat, 
weighing  11  stone  6  lbs.     Her  organs  were  healthy,  except 
that  her  tongue  was  much  furred,  and  her  bowels  were  costive. 
Pulse,   112;  temperature,  99'6°.     Soon  after   admission  she 
suddenly,  in  obedience  to  a  delusion,  took  up  a  chair  and 
threw  it  at  one  attendant,  while  she  seized  another  by  the 
hair  and  hurt  her  considerably,  screaming  out  and  saying  they 
were  going  to  murder  her,  and  that  there  were  devils  in  the 
room.     She  refused  to  take  food  at  first,  saying  it  was  poisoned. 
She  had  to  be  secluded  in  a  bedroom,  where  she  would  some- 
times shout  and  gesticulate  and  make  speeches,  and  carry  on 
conversations  with  imaginary  persons ;  then  she  would  lie  flat 
on  her   back  on  the  floor,  keeping  her  eyes  tightly  shut, 
smiling,  and  never  speaking  at  all  or  answering  questions, 
evidently  living  in  her  morbid  imaginations,  and   trying  to 
exclude    external   sensations — a   very   common   example    of 
exalted    "  subject-consciousness "    and    depressed     "  object- 
consciousness  "   in   acute   mania.      She   did   not   sleep,    and 
was  noisy  all  night  till  the  third  night,  when  she  slept  two 
hours.     On  the  first  day  she  was  so  violent,  and  so  strong, 
and  so  resistive,  that  it  was  thought  desirable  not  to  dress 
her  or  send  her  out.     She  was  got  into  a  warm  bath  with 
great  difiiculty.     Her  temperature  rose  to  100°.     It  was  the 
fourth  day  before  she  began  to  take  more  food  than  a  little 
milk,  or  before  we  could  'get  her  dressed  and  out  in  the  open 
air  much.     Her  bowels  had  been  costive  till  then,  as  she 
could  not  be  got  to  take  any  medicine.     She  then  had  croton 
oil  giv-en  her  and  an  enema,  and  had  a  free  evacuation  of 
most  offensive  faeces.     Her  breath  had  been  very  foul.     On 
the  sixth  day,  though  she  was  drinking  a  good  deal  of  milk 


184  STATES   OF   MENTAL   EXALTATION. 

and  custards,  her  tongue  and  mouth  got  dry  and  cracked,  her 
pulse  weak,  and  she  showed  signs  of  exhaustion.  She  was 
put  on  four  glasses  of  wine,  and  still  kept  out  in  the  fresh  air, 
while  a  little  milk  was  given  her  every  half  hour.  She  was 
very  excited,  noisy,  destructive,  and  absolutely,  dehrious  and 
incoherent.  She  had  passed  into  the  "dehrious  mania," 
which  some  authors  set  up  as  a  special  variety.  On  the  tenth 
day  the  excitement  began  to  abate,  her  tongue  and  mouth 
became  moist ;  she  became  more  manageable,  and  got  a  good 
night's  sleep  for  the  first  time.  In  a  month  from  the  time  of 
her  admission  she  had  lost  twenty-four  pounds  in  weight,  but 
then  the  acuteness  of  the  brain  exaltation  passed  off.  She 
had  "  a  good  day  and  a  bad  one,"  could  sit  down  to  meals, 
and  eat  her  food.  She  could  walk  about,  looking  moderately 
sane  to  anyone  at  a  little  distance.  She  could  answer  simple 
questions  correctly.  She  began  to  have  doubts  as  to  a  delusion 
about  my  being  her  husband,  saying,  in  answer  to  my  question 

as  to  who  I  was — "  You're  John ,  at  least  you  look  like 

him ;  but  I'm  thinkin'  you're  no  him."  She  made  a  perfect 
recovery  in  four  months. 

The  following  is  a  case  of  acute  mania  coming  on  in  an  liour 
loitJi  great  intensity,  and  gradual  hut  not  comjjlete  ?'ecovery  in 
three  months.  Relapse  after  three  and  a  half  years,  attack  of 
ten  months^  duration,  complete  recovery. 

C.  M.,  set.  17.  Diathesis  nervous.  Disposition  excitable 
and  sensitive.  Comes  of  a  nervous  stock ;  and  a  maternal 
cousin  is  insane.  He  had  been  in  low  spirits,  and  rather  more 
sensitive  and  shrinking  than  usual.  There  was  no  proof  of 
masturbation,  though  I  supposed  that  liis  thoughts  had  been 
erotic  from  various  small  indications.  Being  very  strictly 
brought  up,  all  the  outward  influences  had  been  in  favour  of 
severe  repression  of  the  nisus  generativus.  The  exciting  cause 
was  said  to  have  been  a  fright,  but  I  scarcely  tliink  there  was 
sufficient  proof  of  this.  One  day  he  suddenly  began  to  roar 
and  shout,  and  say  he  was  first  Christ  and  then  the  devil,  and 
to  be  very  violent  to  those  about  him.     He  got  so  ill  and  so 


STATES   OF  MENTAL  EXALTATION.  185 

unmanageable  that  he  had  to  be  removed  to  the  Asykim  the 
same  night  his  attack  began,  which  in  most  cases  would  be 
considered  a  premature  measure,  considering  the  possibility  of 
mania  transitoria,  the  pubHc  feeling  existing  about  hospitals 
for  the  insane,  and  the  harm  a  residence  in  one  may  do  to  a 
man's  prospects,  however  much  it  may  be  true  that  the  best 
treatment  for  the  patient  can  be  got  there.  His  delusions 
were  transient,  most  of  them  being  of  a  rehgious  nature.  His 
condition  was  that  of  typically  acute  delirious  mania  when  let 
alone,  but  when  his  attention  was  roused  by  questioning  he 
could  answer  some  simple  questions  coherently  though  not 
correctly,  his  memory  being  much  impaired.  He  was  slightly 
built,  not  so  fat  as  he  should  have  been ;  his  pulse  very  weak, 
116,  and  his  temperature  99"6°,  and  100°  in  the  evening.  He 
had  a  warm  bath  at  98°,  with  cold  cloths  to  his  head  for 
fifteen  minutes,  and  a  draught  of  10  grains  of  chloral  and  45 
grains  of  bromide  of  potassium,  with  2  drachms  of  tincture  of 
valerian.  He  scarcely  slept  at  all,  and  next  day  his  condition 
was  still  very  excited  and  violent,  but  he  was  kept. walking 
about  by  two  attendants  for  five  hours,  though  very  intractable, 
throwing  himself  about,  &c.  ISText  night  he  got  a  bath  for 
twenty  minutes,  and  the  same  draught,  and  slept  six  hours. 
Next  day  his  temperature  was  normal.  He  was  less  excited, 
and  walked  better.  The  same  treatment  was  continued,  in 
three  days  he  was  still  better,  and  in  eight  days  he  was  playing 
cricket.  He  had  a  relapse  on  the  tenth  day,  though  he  did 
not  get  nearly  so  excited  as  at  first.  He  had  two  or  three 
milder  relapses  within  the  next,  two  months,  but  at  the  end  of 
that  time  he  was  practically  well,  and  in  three  months  he  was 
discharged  recovered.  His  treatment  consisted  of  an  indefinite 
allowance  of  milk  and  eggs,  almost  no  animal  food,  fresh  air, 
exercise  to  fatigue  all  day,  baths,  warm  at  first,  and  mild 
shower  baths  as  he  recovered,  and  cod-liver  oil  emulsion,  with 
the  hypophosphite  of  Hme.  He  gained  almost  a  stone  in 
weight,  but  did  not  grow  any  more  manly  in  his  form,  nor  did 
his  beard  grow.  .         . 


186  STATES   OF  MENTAL  EXALTATION. 

He  kept  well  enough  not  to  he  sent  to  tlie  Asylum  for  tliree 
and  a  half  years,  but  during  that  time  he  constantly  had 
threatenings  of  his  complaint,  and  was  at  times  unable  to 
follow  any  continuous  occupation.  After  that  time  he  had 
another  attack  of  a  much  more  mild  kind  of  acute  mania. 
He  was  dehrious,  not  violent,  early  ceasing  to  take  any 
interest  in  anything,  seeming  to  Hve  in  a  morbid  subjective 
mental  atmosphere  of  disordered  imagination;  talking  to 
himself  incessantly,  not  sleeping  well,  was  constantly 
grimacing,  gesticulating  and  fighting  imaginary  persons  in 
the  room  round  the  wall.  When  he  was  spoken  to  he  would 
pick  himself  up  and  answer  pretty  rationally.  This  is  a 
condition  that  puzzles  many  persons.  It  looks  like  dementia, 
while  in  reality  it  is  a  subacute  form  of  mania,  which  makes 
all  the  difference  in  the  prognosis  and  sometimes  in  the  treat- 
ment. He  was  tried  at  home,  in  charge  of  an  attendant  to 
control  him,  to  get  him  to  walk  out,  &c.,  but  he  rather 
rebelled.  Patients  are,  of  course,  never  so  easily  controlled 
at  home  as  away  from  it ;  especially  it  is  hard  for  the  master 
or  mistress  of  a  household  to  be  controlled  in  their  own  house, 
where  before  every  one  was  under  them.  In  an  institution, 
on  the  contrary,  among  strangers,  under  certain  definite  rules 
of  living,  and  where  there  is  obviously  the  means  of  enforcing 
medical  orders,  a  patient  must  be  very  insane  not  to  conform 
to  the  orders  given  as  to  his  treatment,  and  to  the  general 
way  of  hving  of  the  place.  This  is  very  often  seen  when 
patients  come  to  asylums.  At  home  they  had  been  difficult 
to  manage,  or  very  obstinate,  while  from  the  moment  they 
came  into  the  institution  they  gave  Kttle  trouble. 

He  had  again  to  be  sent  to  the  Asylum,  and  he  was  found 
to  have  lost  in  weight,  and  to  be  ill-nourished  and  wanting  in 
nervous  tone  and  nutritive  energy.  His  muscles  were  flabby 
and  his  skin  pale,  and  his  appetite  for  food  not  keen.  He 
was  put  on  quinine  and  iron,  cod-Uver  oil,  milk,  and  eggs  in 
large  quantities ;  his  skin  was  well  rubbed  night  and  morning 
with  a  dry  towel ;  he  got  mild  shower  baths,  and  took  much 


STATES  OF   MENTAL  EXALTATION.  187 

and  increasingly  vigorous  exercise.  He  gradually  gained  in 
weight,  in  nervous  tone,  in  self-control,  in  power  of  applying 
himself  to  work,  in  his  interest  and  power  of  attention;  he 
got  more  manly  in  form,  and  filled  out  into  a  strong  vigorous- 
looking  young  man.  It  took  him  ten  months  to  recover. 
This  was  a  case  in  which  I  was  very  much  afraid  of  dementia. 
I  think  this  would  have  resulted  had  not  right  treatment 
been  vigorously  adopted.  In  such  a  case  the  brain  is  in  much 
the  same  state  as  in  certain  forms  of  dementia,  plus  a  little 
maniacal  excitement — but  that  makes  all  the  difference. 
Almost  never  pronounce  a  case  incurable  while  there  is 
exaltation  remaining. 

A  very  Acute  Case  with  High  Temperature. — I  had  once 
under  my  care  C.  N.,  a  young  lady  of  twenty-three,  of  a 
nervous  diathesis,  and  with  a  strong  heredity  to  insanity, 
who,  bathing  while  menstruating,  became  slightly  depressed, 
then  had  an  attack  of  slight  exaltation  every  month,  followed 
by  a  day  or  two  of  modified  stupor,  at  the  time  she  should 
have  menstruated  but  did  not.  After  a  few  months 
menstruation  returned,  but  came  on  every  fortnight,  thus 
reducing  her  strength,  and  causing  anaemia.  At  the  usual 
time  of  menstruation  on  one  occasion  a  most  violent  attack  of 
acute  mania  came  on,  with  incoherent  delirium  and  such  ex- 
cessive violence  that  she  nearly  killed  a  relation.  Two  trained 
female  attendants  could  not  control  her  at  home.  Her  tempera- 
ture was  103°,  one  of  the  highest  I  ever  saw  from  uncomplicated 
brain  exaltation  not  puerperal,  and  she  had  to  be  taken  to 
the  Asylum  within  twenty-four  hours  after  the  commencement 
of  the  attack.  For  the  first  fortnight  she  remained  in  the 
most  acute  state  of  excitement  I  think  I  ever  saw.  It  took 
five  attendants  to  restrain  her,  dress,  undress,  and  have  her 
walked  out,  which  we  did  every  day.  When  she  would  not 
walk  she  Was  allowed  to  roll  on  the  ground.  She  soon  became 
less  excited,  but  at  the  next  menstrual  time  she  had  a  relapse, 
and  was  as  ill  as  on  admission.  Though  apparently  absolutely 
delirious  and  without  power  of  attention  when  excited,  yet. 


188  STATES   OF  MENTAL  EXALTATION. 

when  the  attack  passed  off,  she  could  describe  what  had 
occurred  very  accurately  for  the  most  part,  though  distorted 
in  some  respects.  She  had  no  realisation  that  she  had  been  so 
ill,  and  therefore  thought  she  was  unnecessarily  detained  in  the 
Asylum,  and  that  the  attendants'  restraint  of  her  violence  had 
been  simple  cruelty  on  their  part.  There  is  a  psychological 
fact  with  which  we  are  very  f amihar  in  asylums,  which  was 
most  marked  in  her  case,  though  it  occurs  more  or  less  in  most 
cases  of  mania  and  melanchoHa.  As  the  patients  first  become 
coherent  and  sensible  they  are  much  more  unreasonable  about 
"going  home  at  once,"  and  about  getting  all  they  fancy,  and 
about  being  controlled,  and  about  all  sorts  of  things,  than 
when  they  get  quite  well.  They  usually  attribute  any  nervous 
symptoms  they  have  to  their  being  "kept  in  the  asylum,"  and 
aver  with  daily  iteration  that,  if  kept  much  longer  "in  a  mad- 
house "  or  "  among  maniacs,"  they  will  certainly  become  insane. 
The  stage  of  convalescence  is  the  stage  of  irritability  and 
unreason  in  many  cases.  Their  friends  do  not  understand 
that  this  is  the  ordinary  half-way  house  to  complete  recovery, 
and  sometimes  remove  them  home,  often  with  very  bad  results. 
"Wlien  they  have  quite  recovered,  such  patients  are  commonly 
reasonable  about  going  home,  and  often  recognise  how  necessary 
restraint  has  been.  Some  patients  never  do  this,  however. 
C.  N.  had  relapses  of  a  less  severe  character  about  the  men- 
strual periods,  getting  more  and  more  reasonable  during  the 
intervals.  In  six  months  she  was  so  well  that  she  was  taken 
home,  not  exactly  against  my  advice,  but  not  quite  with  my 
concurrence,  as  she  had  not  menstruated,  and  was  excitable. 

Tests  of  Recovery. — The  question  of  when  recovery  has 
taken  place  is  often  a  difficult  one  to  decide  in  mental  diseases. 
You  have  to  take  the  temperament,  disposition,  and  normal 
state  of  mind  and  conduct  into  account.  The  same  standard 
cannot  be  applied  to  persons  of  different  education,  tempera- 
ment, or  nationality.  I  lately  had  a  young  lady  patient  who 
was  so  excitable  and  lively,  so  reckless  in  speech  and  conduct, 
after  all  the  acute  symptoms  had  passed  off,  that  I  had  to 


STATES   OF   MENTAL   EXALTATION.  189 

send  for  her  relations  to  tell  me  whether  she  had  returned  to 
her  normal  state  or  not,  and  I  found  she  had  done  so  and  was 
well.  She  soon  got  married  and  had  children,  and  settled 
down  into  a  staid  and  sensible  matron  and  mother,  her  surplus 
stock  of  nervous  energy  finding  its  natural  outlet,  and  her 
organic  cravings  their  physiological  satisfaction,  but  alas  !  for 
the  world's  stock  of  future  sanity  in  such  cases. 

Menstruaiion. — The  relation  of  menstruation  to  mental 
disease  is  a  very  important  one,  of  which  I  shall  treat  more 
fully  under  uterine  insanity ;  but  I  may  say  now  generally 
that  in  most  cases  of  acute  mania  cessation  is  the  consequence 
and  one  symptom  of  the  morbid  brain  excitation,  and  not  its 
cause,  and  the  restoration  of  the  function  is  the  result  of 
improved  brain  and  bodily  health  and  condition.  I  seldom 
adopt  special  means  for  its  restoration  until  the  patients  are 
strong  and  have  become  fat,  but  at  the  same  time  I  regard 
mental  recovery  in  a  woman  as  being  hkely  to  be  much  more 
stable  and  less  liable  to  relapse  after  the  menstrual  function 
has  become  normal.  I  always  like  to  see  it  normal  before  I 
recommend  the  patient's  removal  from  the  Asylum. 

The  treatment  in  C.  N.'s  case  was  exactly  the  same  as  that 
of  C.  M.  Unfortunately,  she  was  threatened  with  a  relapse 
after  going  home,  but  it  was  summer,  and  I  sent  her  to 
vegetate  and  Uve  in  the  fresh  air  at  the  sea-side,  where  her 
recovery  was  completed.  She  then  went  to  work,  and 
worked  too  hard,  and  has  since  had  several  attacks  of  the 
same  kind,  but  of  shorter  duration  and  sHghter  character,  in 
the  ten  years  that  have  elapsed  since  her  first  recovery. 

Both  of  these  last  two  cases  (C.  M.  and  G.  IS".),  though 
cases  of  acute  mania  in  the  classification  founded  on  mental 
symptoms,  are  cases  of  the.  insanity  of  adolescence  when  looked 
at  from  the  clinical  point  of  view. 

Though  recovery  from  acute  mania  is  usually  a  gradual  pro- 
cess, yet  at  times  it  is  sudden.  Why  this  should  be  in  certain 
patients  I  am  quite  unable  to  teU,  nor  have  we  any  means  of 
predicting  beforehand  in  any  case  that  it  will  terminate  in 


190  STATES   OF   MENTAL  EXALTATION. 

recovery  in  that  sudden  way.     This  is  an  example  of  acute 
mania  lohich  was  cured  suddenly  by  a  local  inflammation. 

C.  0.,  set.  44,  a  married  woman,  with  several  children. 
K"©  hereditary  predisposition,  the  sole  cause  heing  over-work 
in  her  household  and  over-anxiety  ahout  her  family.  She 
Avas  of  an  "  anxious  disposition "  and  ^  nervous  diathesis. 
She  became  irritable,  quarrelsome,  restless,  sleepless,  excited, 
and  totally  changed  from  her  natural  ways  ahout  a  week 
before  her  admission,  and  this  condition  has  quickly  passed 
into  one  of  acute  maniacal  exaltation,  noisiness,  singing, 
fleeting  delusions,  violence,  and  excitement,  with  no  memory, 
no  self-control,  and  no  affection  for  her  children,  of  whom  she 
had  been  passionately  fond.  Sometimes  she  would  be  taciturn 
and  obstinate  for  an  hour  or  two,  would  not  open  her  eyes, 
answer  questions,  eat,  or  walk  about.  She  had  not  slept  for 
several  nights  before  admission,  and  had  refused  food.  When 
brought  to  the  Asylum  she  was  acutely  excited,  noisy,  shout- 
ing, singing,  gesticulating,  strugghng,  resisting,  violent, 
making  faces  and  facial  contortions,  putting  her  tongue  out, 
but  would  not  answer  questions  or  attend  to  anything  said  to 
her.  The  common  sensibility  seemed  quite  blunted,  so  that 
she  felt  no  pain.  Her  skin  was  dry,  tongue  furred  and  dry, 
appetite  gone.  Pulse  126,  small  and  weak.  Temperature, 
101*2°.  For  the  first  four  days  she  remained  in  this  state, 
taking  scarcely  enough  food,  and  that  with  extreme  difficulty, 
and  spending  her  time  partly  out  of  doors,  under  the  care  of 
two  attendants,  and  partly  in  the  padded  room  when  in  the 
house.  On  the  fifth  day,  having  refused  food  altogether,  she 
was  fed  with  the  stomach  pump.  This  was  done  with  extreme 
difficulty  on  account  of  her  holding  her  teeth  together  most 
closely.  The  steel  mouth-opener,  though  padded  with  tape, 
she  crushed  throixgh  a  tooth  by  the  force  with  which  she  bit 
it.  This  caused  a  good  deal  of  inflammation  in  the  gums  and 
jaw,  spreading  back  to  the  parotid  gland,  which  became 
enormously  swollen  and  suppurated.  But  as  the  inflammation 
spread  the  maniacal  condition  subsided,  so  that  on  the  tenth 


STATES  OF   MENTAL  EXALTATION.  191 

day,  when  the  temperature  was  106°  and  the  patient  very- 
weak  and  exhausted  indeed,  the  restlessness  and  excitement 
had  quite  ceased,  and  she  took  both  food  .and  stimulants. 
She  was  confused  in  mind,  hut  not  otherwise  maniacal ;  and, 
though  she  nearly  died  from  the  combined  general  exhaustion 
and  local  inflammation,  she  never  became  maniacal  again, 
steadily  progressed  towards  recovery,  mental  and  bodily,  and 
was  well  in  a  month. 

Parotitis. — The  inflammation  of  the  parotid  gland  which 
occurred  in  the  case  I  have  met  with  in  various  forms  of 
mental  disease — acute  mania,  melancholia,  puerperal  insanity, 
&c.  In  two  cases  it  caused  death  from  suppuration  and 
septicaemia.  The  cause  of  it  varies  in  difl"erent  cases.  It 
cannot  be  often  caused,  as  is  alleged  by  one  author,  through 
attendants  holding  the  head  during  feeding. 

Septic  Fever  cutting  short  Attacks. — That  is  one  example  of 
very  many  cases  I  have  met  with,  where  a  local  inflammation, 
a  fever,  an  internal  disease,  a  carbuncle,  a  crop  of  boils,  or 
septic  blood-poisoning,  have  cured  insanity.  We  try  to  do 
the  same  thing  sometimes  in  cases  that  are  strong  in  body  by 
severe  blistering,  but  seldom  succeed  in  producing  the  same 
marked  and  immediate  effect.  I  have  always  beheved  that  some 
day  we  should  hit  on  a  mode  of  producing  a  local  inflamma- 
tion or  manageable  septic  blood-poisoning,  by  which  we  should 
cut  short  and  cure  attacks  of  acute  mania.  Dr  Lewis  C.  Bruce 
has,  by  means  of  his  heroic  doses  of  thyroid  extract  (see  p.  133), 
largely  succeeded  in  this  mode  of  terminating  many  attacks  of 
maiiia.  I  have  been  much  impressed  by  some  of  his  cases. 
But  such  intercurrent  diseases  do  not  always  cure  mental 
attacks.  I  have  often  seen  them  occur  in  cases  of  acute 
mania  and  do  no  good.  I  suppose,  in  fact,  the  failures 
may  be  more  numerous  than  the  successes,  but  the  latter 
naturally  make  more  impression  on  one's  mind  and  loom 
larger  in  one's  field  of  experience.  Tlie  following  was  a  very 
striking  case  of  cure,  sudden  and  unexpected,  after  hope  had 
been  nearly  given  up,  through  septic  fev^r ;— ^ 


192  STATES   OF  MENTAL  EXALTATION. 

C.  P.,  eet.  26,  a  married  woman,  who  liad  for  nine  months 
suffered  from  acute  mania  connected  with  lactation.  The 
symptoms  had  come  to  have  some  of  the  mental  enfeeblement 
of  dementia  ahout  them,  hut  still  there  was  the  maniacal  ex- 
citement, the  presence  of  which  prevented,  in  my  mind,  an 
absolutely  unfavourable  prognosis.  She  had-  been  discharged 
from  another  asylum  as  virtually  incurable.  She  had  several 
cuts  on  her  hand  on  admission,  caused  by  her  having  broken 
a  window.  Fortunately  for  her  one  of  them  got  some  dirt  into 
it,  and  the  hand  inflamed  badly,  with  a  nasty  septic-looking 
inflammation  that  ran  up  the  lymphatics,  and  was  attended 
by  intense  pain  and  great  general  disturbance  and  prostration. 
It  suppurated,  and  discharged  a  dirty  sanious  pus.  But  the 
effect  on  the  brain  condition  was  magical.  This  nine  months' 
maniacal,  destructive,  dirty,  violent  woman,  caring  nothing 
for  her  husband  or  children  or  the  common  decencies  of  Hfe, 
became  quite  gentle  and  manageable  as  the  inflammatory 
fever  and  the  local  inflammation  progressed.  At  first  confused 
in  mind,  then  awakening  to  all  the  former  associations  of  her 
Hfe,  she  inquired  for  her  children,  and  became  in  a  fortnight  a 
sane,  pleasant,  lady -like  woman,  with  all  the  charms  and  graces 
of  womanhood.  Such  cases  puzzle  one  exceedingly.  That 
period  of  nine  months,  during  which  the  neurine  of  the  brain 
convolutions  had  been  energising  morbidly,  so  that  every  mind 
function — intellectual,  affective,  instinctive,  and  mnemonic 
— was  utterly  disordered,  clearly  left  no  trace  of  struc- 
tural change.  Unfortunately  I  have  to  give  the  sequel,  which 
is  not  so  pleasant.  She  kept  quite  well  for  three  years, 
had  a  cMld,  and,  while  nursing  it  (neither  of  which  she  ever 
ought  to  have  done),  another  child  died,  causing  her  great  grief. 
She  again  became  maniacal.  I  blistered  her  head  repeatedly 
and  severely,  and  rubbed  in  irritants  with  marked  benefit, 
but  not  with  such  absolute  and  striking  effect  as  on  the  first 
occasion,  because  probably  I  could  not  set  up  a  really  septic 
fever.  I  put  her  on  bromide  of  potassium  and  cannabis  indica 
with,  very  marked  benefit.     She  ^ot  better  in  four  months, 


STATES   OF   MENTAL   EXALTATION.  193 

and  went  home  quite  well  in  all  respects.  In  a  year  she 
became  maniacal  again,  and  this  time  no  treatment  has  been 
of  any  avail.     She  remains  ill  and  is  now  incurable. 

Hot  Baths. — The  good  effect  of  treatment  of  acute  mania  by 
hot  baths  was  well  seen  in  the  folloiving  case  of  C.  P.  A.,  a 
young  man  who,  as  the  result  of  over- work  and  too  little  fresh 
air  and  relaxation,  became  morbidly  exalted  in  mind,  restless, 
sleepless,  talkative,  and  changed  in  general  mental  demeanour. 
While  in  this  state  he  was  more  active  mentally  than  he  had 
ever  been  in  his  life.  He  wrote  an  article  for  the  most 
brilHant  weekly  journal  of  the  time,  which  was  accepted  and 
inserted — the  only  such  article  he  ever  wrote  in  liis  hfe.  His 
condition  soon  passed  into  violent  excitement,  constant 
extravagant  talking,  and  fleeting  delusions  of  ambition  and 
extravagance.  His  conduct  became  violent,  destructive,  and 
unmanageable,  and  he  was  in  that  condition  when  I  saw  him. 
I  got  a  first-rate,  strong,  trained  attendant,  and  we  gave  him 
two  baths  of  about  104°,  with  cold  to  his  head.  The 
immediate  effect  of  this  was  lowering,  and  he  nearly  fainted 
before  he  was  taken  out  of  the  second,  but  his  excitement 
and  talkativeness  and  his  delusions  were  calmed  and 
diminished.  He  got  drachm  doses  of  the  bromide  of  potassium 
repeated  three  times  during  the  night,  and  for  the  first  time 
for  about  ten  days  he  had  a  good  sleep.  By  the  way,  I 
should  have  mentioned  that  between  the  baths  he  was  taken 
out  into  the  open  air  and  walked  about  for  several  hours  till 
he  was  pretty  nearly  exhausted.  JS'ext  morning  all  the  most 
violent  and  unmanageable  of  the  symptoms  were  found  to 
have  passed  off,  and  under  the  treatment  of  baths  and  bromide, 
with  plenty  of  exercise  and  unlimited  milk  and  liquid  nourish- 
ment, he  made  a  speedy  and  perfect  recovery  in  about  a  week 
or  ten  days,  without  relapse  and  without  complication.  In  a 
fortnight  he  was  able  to  go  away  for  a  change,  and  for  ten 
years  was  as  vigorous,  mentally  and  bodily,  with  two  short 
and  slight  exceptions,  as  he  ever  was,  conducting  a  large 
business. 

N 


194  STATES   OF   MENTAL  EXALTATION. 

Death  from  Exhaustion. — Acute  mania  sometimes  exhausts 
tlie  strength  of  the  patient,  and  kills  in  spite  of  treatment,  as 
in  the  following  case  of  C.  Q.,  set.  34,  suffering  from  the 
third  attack  of  mental  disease,  the  two  former  having  been 
attacks  of  melancholia.  She  had  a  sister  insane,  and  a  brother 
an  imbecile.  She  had  been  ill  for  about  a  month,  being  much 
excited,  and  refusing  food.  On  admission  she  was  acutely 
maniacal  and  dehrious,  with  no  memory,  and  no  power  of 
attention.  Her  pulse  was  98°,  her  temperature  99"6°,  and  her 
general  condition  weak.  She  refused  food,  and,  though  fed 
regularly  with  the  stomach  pump,  the  excitement  continued, 
and  she  got  more  and  more  exhausted,  though  after  the  first 
feeding  with  custard,  wine,  and  quinine  she  was  less  excited, 
and  slept  for  the  first  time  for  a  week,  but  this  good  result 
did  not  continue,  and  she  died  on  the  fifteenth  day.  A  post- 
mortem examination  showed  the  traces  of  old  morbid  action 
in  the  shape  of  thickened  and  adherent  dura  mater,  the 
vessels  of  the  brain  being  engorged  ;  but  its  substance,  so  far 
as  our  means  of  investigation  enabled  me  to  examine  it,  was 
normal.  The  most  common  post-mortem  appearances  in  the 
brain  in  those  cases  that  die  of  acute  mania  are  intense  hyper- 
semic  conditions,  as  represented  in  Plate  lY.  The  constant 
occurrence  of  such  hypereemia  in  hmited  areas  shows  that  the. 
vaso-motor  disturbance  is  not  uniform  all  over  the  brain.  In 
the  case  from  which  Plate  lY.  was  drawn  the  congestion 
occurred  along  the  whole  inner  layer  of  the  grey  substance  of 
the  convolutions  as  well  as  in  areas.  I  have  always  looked  on 
this  irregularity  of  blood  supply  to  the  brain,  resulting  from 
such  vaso-motor  spasms  at  some  parts  and  paralysis  at  others, 
as  being  most  important  in  throwing  light  on  the  general 
pathology  of  acute  insanity,  but  I  scarcely  regard  any  vascular 
disturbance  as  a  primary  cause  of  the  disease,  believing  that 
the  blood-vessels  are  the  servants  and  not  the  masters  of  the 
brain-cells.  I  had  a  case  of  acute  mania  lately  who  died 
within  a  fortnight  of  her  attack,  in  whose  cortex  the  cells  were 
in  a  state  of  marked  degeneration  similar  to  those  shown  in 


STATES   OF   MENTAL  EXALTATION.  195 

Plate  XIII.j  figs.  3,  4,  and  6.     The  question  occurs — Can  such 
cells  recover  their  normal  appearance  1 

An  Undescribed  Deposit  in  Cortex  in  Acute  Mania. — The 
following  case  of  acute  mania  was  accompanied  by  a  patho- 
logical deposit,  of  a  kind  yet  undescribed,  all  through  the 
convolutions.  C.  Q.  A.,  set.  50,  had  been  insane  for  only  a 
few  days,  and  was  acutely  excited  and  maniacal  on  admission. 
Her  temperature  was  98°,  and  her  pulse  88.  She  was 
dehriously  maniacal,  unconscious,  restless,  sleepless,  and 
noisy.  In  a  fortnight  she  became  more  rational  and  quiet, 
and  could  do  some  work.  Then  in  another  week  the  acute 
deliriously  maniacal  condition  returned.  She  got  more 
stupid  and  irrational,  and  died  four  weeks  after  admission 
and  five  weeks  after  the  commencement  of  her  insanity. 
"With  the  late  Dr  Joseph  J.  Brown,  then  the  assistant 
physician  in  charge  of  the  department,  I  made  the  post- 
mortem  examination;  and  the  naked-eye  appearances  were, 
like  the  microscopic  appearances  afterwards  discovered  by 
Dr  Brown,  quite  unique  and  hitherto  undescribed.  The 
pia  mater  was  milky  and  thickened,  and  stripped  readily  off 
the  convolutions.  The  convolutions  were  somewhat  atrophied. 
In  the  convolutions,  scattered  around  the  island  of  Eeil,  there 
were  seen  a  number  of  small  pellet-like  bodies  the  size  of 
pin-heads,  and  of  a  glistening  appearance.  When  closely 
examined  it  was  seen  that  those  sago-like  bodies  were  more 
or  less  distributed  over  the  grey  substance  of  nearly  the 
whole  of  the  convolutions  of  the  cerebrum.  The  outer  layer 
of  the  grey  matter  of  the  convolutions  was  quite  distinct  from 
and  stripped  like  a  sheet  of  wet  paper  off  the  under  layer. 
Dr  Brown  prepared  many  beautiful  carmine-stained  sections 
of  the  convolutions  so  affected,  and,  but  for  his  lamented  and 
premature  death,  was  to  have  fully  described  the  lesion, 
which  was  new  and  very  interesting.  A  deposit  of  a  new 
material  had  taken  place,  as  represented  in  fig.  2,  Plate  II., 
all  through  the  grey  substance  of  the  convolutions,  but  chiefly 
in  its  inner  layers,  and  extending  in  some  parts  into  the  white 


196  STATES    OF   MENTAL   EXALTATION. 

substance.  It  was  in  some  places  in  single  spots,  with  a 
nucleus  in  the  centre  of  each,  but  no  other  trace  of  organis- 
ation visible ;  in  other  places  in  immense  lobulated  masses, 
or  in  great  oval  bodies  with  a  nucleus  in  the  centre  of  each, 
quite  visible  to  the  naked  eye.  It  was  deposited  in  masses 
round  the  arteries  in  many  places.  It  seemed  as  if  at  the 
least  two-thirds  of  all  the  grey  substance  of  the  convolutions 
affected  were  replaced  by  this  deposit.  It  took  on  the 
carmine  stain  strongly,  and  looked  more  like  a  waxy  material 
than  anything  else,  but  its  exact  composition  I  do  not  know. 
It  was  evident  that  it  was  a  chemico-vital  product  deposited 
round  nuclei. 

Many  questions  suggest  themselves  in  considering  such  a 
case.  What  a  comfort  it  would  be  were  the  pathology  of 
every  case  of  acute  mania  as  definite  as  this  seemed  to  be  ! 
The  discouraging  thing  is,  that  no  such  deposit  is  needed  at 
all  to  produce  mental  symptoms  like  those  of  C.  Q.  A.  How 
long  was  this  deposit  in  forming  1  Surely  longer  than  the 
five  weeks  she  was  insane.  And  she  became  wonderfully 
rational  and  coherent  after  the  first  three  weeks,  with  her 
brain  convolutions  diseased  in  this  way,  just  as  a  general 
paralytic  often  gets  almost  rational  for  a  time  with  his  con- 
volutions diseased.  It  is  clearly  not  only  a  deposit  of  this 
kind,  or  a  pathological  change  in  the  cells,  but  the  morbid 
energising  that  such  lesions  give  rise  to,  that  really  produce 
the  symptoms  of  acute  mania. 

Dr  Blandford^  describes  "  acute  mania  "  as  being  "  a  very 
difi'erent  disorder  "  from  "  acute  delirious  mania."  Bucknill 
and  Tuke  ^  incline  towards  this  distinction,  but  do  not  clearly 
describe  them  as  distinct  from  each  other,  while  Savage  ^  and 
Bevan  Lewis  ^  describe  "  acute  dehrious  mania "  as  distinct 
from  "  acute  mania."     Lewis  gives  thi'ee  cases,  one  of  whom 

^  Insanity  and  its  Treatiiwnt,  by  G.  Fielding  Blandford. 

^  Psychological  Medicine,  by  J.  C.  Bucknill  and  D.  Hack  Tuke. 

2  Insanity  and  Allied  Neuroses,  by  G.  H.  Savage. 

4   Qp^  cii^ 


STATES   OF   MENTAL   EXALTATION.  197 

was  admittedly  in  the  first  stage  of  general  paralysis.  Ball^ 
and  the  French  authors  are  definite  in  their  descriptions  of 
the  delire  aigu,  as  distinct  from  ordinary  acute  mania;  and 
KrafFt-Ebing  is  equally  decided.  Dr  Luther  Bell's  Typho- 
mania  is  commonly  quoted  as  if  it  were  an  extreme  example 
of  this  disease.  I  cannot  agree  that  there  is  any  such  real 
distinction  between  these  forms  of  mania  as  even  to  enable 
us  to  make  them  distinct  clinical  varieties,  for  the  following 
reasons  : — 1.  In  almost  all  cases  of  "  acute  delirious  mania" 
there  is  at  the  beginning  or  end  a  stage  of  ordinary  acute 
mania.  2.  Savage's  psychological  and  clinical  diff'erences, 
so  far  as  they  exist,  are  in  degree,  not  in  kind.  3.  The 
differences  in  prognosis  are  not  according  to  fact.  4.  There 
is  no  real  pathological  difi'erence  so  far  as  we  know.  Kraff't- 
Ebing's  theory  that  the  delirious  form  is  due  to  cerebral 
hyperaemia  clearly  puts  a  result  as  a  cause. 

Delusional  Mania.— T\\i&  is  a  condition  analogous  to  what 
I  have  described  as  delusional  melancholia,  the  general 
symptoms  being  maniacal  instead  of  melancholic,  and  centring 
round  a  fixed  delusion  or  set  of  delusions.  I  have  now 
under  my  care  a  woman — C.  Q.  B. — who  shouts,  scolds,  and 
is  violent  almost  all  day,  alleging  as  the  reason  of  her  con- 
duct that  her  children  are  below  the  boards  of  the  floor,  and 
that  she  hears  them  being  tortured  by  villains  who  are  to  kill 
them.  I  have  a  man  who  shouts  and  preaches,  and  warns 
the  sinners  of  the  world  in  a  most  riotous  and  noisy  way  of 
the  doom  that  awaits  them,  saying  that  the  Lord  had  com- 
missioned him  to  do  so.  Delusional  mania  is  in  fact  delusional 
insanity  plus  maniacal  conduct.  Such  cases  sometimes  recover, 
but  when  the  fixed  delusional  condition  has  lasted  long  the 
prognosis  is  bad. 

Chronic  Mania.— T\ns,  is  simply  acute  mania  running  into 

a  chronic  course.      The  division  line  that  marks  off"  acute 

from  chronic  mania  must  always  be  an  imaginary,  arbitrary, 

and  unscientific  one.    The  term  of  twelve  months  that  I  have 

1  Lc(;ons  sur  Les  Maladies  MentaUs,  by  B.  Ball. 


198  STATES   OF  MENTAL  EXALTATION, 

adopted  lias  this  disadvantage,  tliat  after  that  time  many  cases 
are  curable,  while  we  usually  think  of  chronic  mania  as  being 
virtually  an  incurable  disease,  ending  in  death  or  dementia. 
The  long  continuance  of  a  maniacal  condition  of  the  brain 
always  causes  an  alteration  of  the  symptoms,  as  compared 
with  those  of  recent  acute  mania.  "We  seldom  or  never  have 
any  tendency  to  deHrious  mania,  with  dry  tongue,  high 
temperature,  and  risk  to  life,  from  the  intensity  of  the  disease. 
To  be  able  to  hve  long,  suffering  from  chronic  mania,  impHes 
a  strong  constitution,  with  good  digestive  and  assimilative 
power.  Though  the  absolute  sleeplessness  of  acute  mania 
is  not  present,  yet  many  cases  of  chronic  mania  sleep  exceed- 
ingly little.  It  may  seem  incredible,  but  we  had  once  at 
Morningside  a  woman  suffering  from  chronic  mania,  who  for 
eighteen  months  was  never  found  asleep  by  the  night  attend- 
ant, who  visited  her  every  two  hours  every  night.  She  must 
have  slept,  of  course,  but  her  sleep  was  so  hght  and  so  short 
that  she  was  always  awake  every  two  hours.  K'ot  only  did 
she  not  sleep,  but  she  was  restless,  noisy,  singing,  tearing  her 
bedding,  and  when  she  had  nothing  else  to  do,  gnawed  with 
her  teeth  and  scratched  with  her  nails  the  wood- work  of  her 
room,  into  great  holes.  But  some  cases  of  chronic  mania 
sleep  quite  well,  and  almost  the  natural  time,  and  yet  during 
the  day  they  continue  excited,  restless,  and  destructive. 

There  is  usually  a  spice  of  the  enfeeblement  of  mind  of 
dementia  in  chronic  mania.  Notably  the  memory  is  impaired, 
a  rational  interest  in  anything  cannot  be  roused,  and  the 
habits,  instincts,  and  fine  feehngs  are  degraded  or  dulled. 
The  affective  power  is  usually  almost  paralysed.  There  is  no 
proper  care  for  children  or  tender  affection  for  anybody. 
Yet  some  of  the  cases  remain  most  acute  and  observing  for 
many  years.  One  such  case  I  have,  of  many  years'  duration, 
who  will  always  notice  and  remark  on  any  change  in  my 
dress  before  any  one  else  does  so. 

Some  of  the  pathological  appearances  found  in  chronic 
mania  are  depicted  in  Plate  XIII.  figs.  2  and  6.     They  consist 


STATES   OF   MENTAL   EXALTATION.  199 

of  degenerations  and  partial  atrophy  of  the  cortex  cells,  with 
vascular  and  lymphatic  changes. 

Treatment  of  Chronic  Mania. — As  regards  treatment,  an 
asylum  is  the  only  proper  place  for  such  patients.  I  have 
seen  them  kept  at  home,  or  boarded  in  private  houses,  but 
I  have  seldom  seen  a  patient  very  happy  there,  or  the 
arrangement  very  satisfactory.  I  shall  never  forget  a  visit 
I  once  paid  to  a  case  suflFering  from  chronic  mania — C.  R. 
— with  short  aggravations  each  day  of  wild  delirious  fury. 
To  provide  against  these,  two  large  rooms  in  a  handsome 
villa  had  been  divested  of  furniture,  the  windows  boarded 
up,  and  the  walls  left  to  the  unrestrained  destructiveness 
of  the  patient.  I  stayed  with  her  in  this  apartment  during 
a  paroxysm  of  her  disease,  and,  in  thirty-two  years  of  life 
as  an  asylum  physician,  I  have  never  seen  anything  so 
completely  parallel  to  the  famous  maniac  scene  in  Charlotte 
Bronte's  Jane  Eyre.  The  patient  tore  her  clothes  to  ribbons, 
shouted  and  howled,  and  made  a  barking  noise  like  a  dog, 
bit  her  skin,  dashed  herself  against  the  walls,  and  dug 
into  the  plaster  and  wood-work  with  her  nails  till  they 
bled,  and  she  smeared  the  blood  over  her  face  and  body. 
After  many  years  of  this  life  her  relatives  at  last  got  over 
their  prejudices  against  an  asylum,  and  sent  the  patient 
to  Morningside,  where,  after  a  few  months  of  hard  walking 
in  the  open  air,  occupation,  dancing,  and  a  regulated  life, 
she  is  an  ornamental  and  amusing  member  of  our  community, 
very  happy,  and  always  averse  to  the  idea  of  leaving  the 
Asylum.  She  takes  her  paroxysms  still,  but  they  are  shorter 
and  less  severe.  One  of  the  great  improvements  that  has 
taken  place  in  modern  asylum  management  has  been  that 
rational  physiological  outlets  are  provided  for  the  morbid 
muscular  energy  of  the  cases  of  chronic  mania.  They  are 
neither  confined  in  their  rooms  nor  within  "  airing  courts  " 
enclosed  by  high  walls.  They  are  made  to  walk  about. 
They  are  made  to  wheel  barrows  and  dig  on  farms.  They 
are  encouraged  to  dance,  and  they  are  well  fed.     Most  of 


200  STATES    OF   MENTAL   EXALTATION. 

tliem  eat  enormously,  and  if  tliey  have  not  enough  to  eat 
they  fall  off,  get  worse  in  their  mental  state  and  in  their 
hahits.  Many  of  them  can  be  got  to  expend  their  energies 
in  hard  regulated  work,  and  are  the  very  Lest  workers  on 
the  farms  and  in  the  laundries  of  asylums.  They  are  not 
all,  of  course,  furiously  maniacal.  Some  of  them  simply 
have  a  slight  morbid  excess  and  exaltation  of  function  of 
the  brain  convolutions,  shown  by  talking  or  scolding,  restless- 
ness, want  of  affection,  and  want  of  self-control,  but  are 
not  incoherent.  If  they  are  kept  at  work,  the  most  objec- 
tionable and  repulsive  parts  of  the  older  asylum  life  is 
avoided  in  great  measure,  and  "refractory  wards,"  with 
their  noise  and  danger,  are  not  much  needed.  The  scenes 
with  such  patients — attendants  holding  them  down  and 
removing  them  into  the  seclusion  of  their  own  rooms — are 
few,  K"o  doubt  there  are  risks  run  in  the  present  system 
to  patients  and  their  guardians,  but  I  beheve  the  risks  are 
much  less  in  reahty  than  under  the  old  system,  for  the 
patients  are  not  so  irritable,  not  so  revengeful,  and  not  so 
dangerous  generally. 

The  folio  winy  was  a  case  of  mania,  acute  at  first,  with 
temporary  recovery,  then  a  relapse,  and  chronic  mania  for 
three  years,  then  death, — all  the  mental  symptoms  heing  those 
of  the  ambitious  delirium  of  general  paralysis : — 

C.  Y.,  set.  67.  A  man  of  a  sanguine  temperament,  very 
frank  and  enthusiastic  disposition,  and  industrious  habits. 
For  many  years  he  had  devoted  himself  with  zeal,  enthusiasm, 
and  industry,  as  to  a  real  business  in  life,  to  the  study  of 
a  particular  department  of  knowledge,  until  he  was  one 
of  the  acknowledged  authorities  on  the  matter.  He  was 
a  man  of  much  individuahty  of  character,  amounting  almost 
to  eccentricity,  and  he  evidently  had  a  high  opinion  of 
himself  and  of  what  he  had  done.  His  habits  were  so 
industrious  in  following  his  special  work  that  he  gave 
himself  too  Kttle  sleep,  and  this,  I  think,  was  the  exciting 
cause  of  the  attack  I  am  about  to  describe ;  the  predisposing 


STATES   OF   MENTAL   EXALTATION.  201 

cause  being  a  heredity  to  the  neuroses,  which  some  of  his 
relations  were  so  anxious  to  deny  that  I  conckided  it  must 
exist — in  fact  I  had  evidence,  by  seeing  some  of  them,  of 
its  existence.  His  disease  consisted  of  a  gradual  evolution 
and  exaggeration  of  certain  points  in  his  character  into 
excessive  and  morbid  prominence.  His  good  opinion  of 
himself  and  the  value  of  his  work,  which  before  had  merely 
been  apparent  in  small  things,  now  became  evident  beyoad 
what  sensible  men  ordinarily  display.  He  became  restless ; 
his  sleep  power  seems  to  have  gone,  so  that  he  sat  up  all 
night,  and  he  became  irritable  without  reason.  He  went 
about  among  his  friends,  and  talked  all  the  time,  his  natural 
enthusiasm  about  his  special  work  taking  ridiculous  forms. 
He  developed  openly  an  idea  that  he  seems  to  have  vaguely 
held,  but  did  not  speak  about  it,  that  he  was  the  heir  of 
a  great  Scotch  historical  house.  In  a  certain  nascent  degree, 
the  idea  that  they  are  the  heirs,  or  at  all  events  the  members, 
of  great  historical  or  well-known  families  is  a  most  common 
psychological  peculiarity  of  vast  numbers  of  perfectly  sane 
Scotsmen;  and  when  they  have  attacks  of  morbid  mental 
exaltation  this  vague  fancy,  and  perhaps  longing,  which 
before  had  no  more  practical  effect  on  their  lives  than 
heightening  their  self-respect,  becomes  a  foohshly  expressed 
delusion.  If  I  have  had  one  Lindsay  as  a  patient  who 
was  the  rightful  heir  to  the  earldom  of  Balcarres,  I  have 
had  certainly  a  dozen,  and  every  insane  Stewart  is  of  the 
royal  clan.  In  about  a  fortnight  C.  T.  was  absolutely 
incoherent,  swearing,  and  fancying  he  was  in  heaven,  this 
condition  being  attended  with  great  violence  to  those  about 
him,  and  destruction  of  objects  that  he  had  valued  most 
highly.  In  another  day  or  two  he  became  quite  delirious, 
would  take  no  food,  and  had  to  be  sent  to  the  Asylum. 
On  admission  he  was  maniacal  and  furious,  attacking  those 
near  him  very  violently,  and  at  times  dashing  himself  on 
the  floor  in  a  way  that  might  have  hurt  him.  He  was 
almost  incoherent,  but  his  ideas  were  all  very  exalted.     He 


202  STATES   OF   MENTAL  EXALTATION. 

had  millions  of  money,  could  make  us  all  dukes,  &c.  He 
would  make  a  man  a  duke  one  moment  and  strike  him 
suddenly  the  next.  His  case  was  certainly  very  exceptional 
in  its  tendency  to  impulsive  violence.  He  was  in  this  respect 
more  like  the  dangerous  maniac  of  the  popular  imagination 
than  most  of  our  ordinary  patients.  "With  this  intense 
excitement,  and  with  much  muscular  strength,  his  pulse 
was  feehle,  his  tongue  dry,  lois  face  haggard,  and  his  whole 
bodily  condition  one  of  great  weakness  and  danger  to  his 
life.  By  dint  of  feeding,  stimulants,  and  taking  him  into 
the  open  air  under  the  charge  of  trained  attendants,  he 
gradually  improved.  His  mental  state  was  all  the  time 
exactly  that  intense  exaltation,  that  morbid  mental  "  expan- 
sion," that  "ambitious  dehrium,"  or  "mania  of  grandeur," 
which  we  find  so  commonly  in  general  paralysis,  and  which 
some  physicians  suppose  to  be  characteristic  of  that  disease. 
Everything  about  the  place  was  of  the  finest,  his  treatment 
was  very  skilful,  the  physicians  were  most  eminent,  and 
the  attendants  were  most  kind.  In  the  beginning  of  his 
disease  I  often  was  on  the  look-out  for  the  motor  symptoms 
of  general  paralysis,  without  which  it  is,  of  course,  utterly 
unjustifiable  to  diagnose  that  disease.  In  three  months  he 
had  become  quiet  in  manner,  self-controUed,  and  rational, 
but  had  just  a  suggestion  of  his  former  state  of  mind  in 
being  too  pleased  with  things,  and  too  grateful  for  httle 
kindnesses.  His  friends  thought  him  quite  well,  and  he 
was  removed  home  with  my  approval.  But  he  had  not 
been  home  a  day  when  he  set  to  work  to  his  old  employ- 
ment and  studies  with  a  sort  of  unreasonable  enthusiasm. 
Sitting  up  nearly  aU  night,  he  soon  got  unsettled,  Ms  exalta- 
tion of  mind  came  back;  he  became  dirty  in  his  habits, 
impulsive,  and  utterly  impatient  of  contradiction.  If  his 
orders  were  not  at  once  carried  out  he  would  get  into  a  sort  of 
maniacal  rage.  In  seventeen  days  he  had  to  be  removed  back 
to  the  Asylum,  and,  though  not  so  dehrious  or  so  weak  as  on 
his  first  admission,  he  was  very  excited.     He  would  come  up 


STATES   OF   MENTAL   EXALTATION.  203 

and  be  very  pleased  to  see  you,  and  in  a  moment,  sometimes 
with  some  little  provocation,  such  as  your  not  agreeing  at 
once  with  him  that  he  was  an  earl,  or  sometimes  without,  he 
would  strike  you  suddenly,  very  often  going  down  on  his 
knees  immediately  after,  and  in  a  theatrical  manner  begging 
your  pardon,  and  hoping  he  had  not  offended  you.  In  meet- 
ing you  he  would  come  up  with  a  profound  bow,  and  place 

his  hand  on  his  breast,  and  hope  "  Sir is  well."     His 

insane  grandeur  of  manner  was  often  very  grotesque.  He 
would  talk  for  a  minute  in  this  high-flown  way,  and  ask  per- 
haps for  a  book  or  a  newspaper.  When  he  got  it  he  would 
turn  round,  and  in  a  surreptitious  way  would  tear  it  up.  He 
was  given  to  impish  tricks  and  mischief  of  all  kinds.  His 
habits  were  dirty  in  the  extreme ;  he  tore  his  clothes  and  his 
bedding,  and  he  never  could  be  left  for  a  moment  without 
getting  into  some  mischief.  He  reminded  me  of  the  clown 
in  a  pantomime,  only  combining  with  his  mischief  a  far  more 
magnificent  manner  than  any  clown  could  assume.  This 
went  on  in  spite  of  all  treatment,  medical,  moral,  or  dietetic, 
for  three  years,  at  the  end  of  which  time  he  died  of  internal 
cancer.  The  chronic  mania,  no  doubt,  weakened  his  brain 
functions,  and  he  presented  some  few  of  the  symptoms  of 
brain  enf eeblement  towards  the  end.  His  memory  was  worse, 
he  was  not  so  coherent,  he  was  more  silly  and  childish  in  his 
ways,  and  the  maniacal  symptoms  were  not  quite  so  intense. 

On  post-mortem  examination  we  found  some  thickening  of 
the  membranes,  some  convolutional  atrophy,  some  disease  of 
the  coats  of  the  vessels,  some  local  congestions,  and  some  few 
spots  of  ramollissement,  but  nothing  pathognomonic,  nothing 
so  characteristic  that  by  seeing  it  one  could  say  that  the  man 
laboured  under  chronic  maniacal  exaltation.  This,  of  course, 
merely  shows  the  insufficiency  of  our  then  means  of  brain 
examination,  for  assuredly  there  must  have  been  organic 
changes  after  so  long  a  disturbance  during  life,  and  by  our 
present  methods  we  could  have  demonstrated  them.  That 
any  pathological  changes  will  ever  show  the  special  mental 


204  STATES  OF  MENTAL  EXALTATIOX. 

peculiarities  of  such  a  person — his  ambitious  mania,  liis  lofty 
opinion  of  himself,  his  destructive  tendencies — is  more  than 
we  can  expect,  for  such  things  were  the  evolutions  of  his 
temperament  and  the  skeleton  of  his  normal  mental  frame- 
work, which  the  self-control  that  we  call  sanity  and  the 
customs  of  civilised  life  induce  men  to  hide  and  keep  under, 
just  as  they  do  their  day  dreams  and  their  pet  ambitions. 
The  onset  of  the  cancer,  with  its  cachectic  and  exhaustive 
tendency,  may  have  been  the  exciting  cause  of  the  maniacal 
attack,  and  also  the  reason  why  recovery  did  not  take  place. 

Elements  of  Progtwsis. — The  chances  of  recovery  from 
mania  after  twelve  months'  duration  diminishes  very  much  as 
time  goes  on,  more  so  than  in  the  case  of  melanchoHa;  but 
we  do  not  pronounce  a  case  incurable  for  a  long  time,  so  long, 
in  fact,  as  the  morbid  brain  exaltation  lasts,  and  dementia 
does  not  supervene.  In  the  prognosis  of  mania,  where  there 
is  exaltation  there  is  some  hope.  I  had  a  patient — C.  T.  A. — 
discharged  recovered  five  years  ago,  who  had  been  for  eight 
years  suffering  from  chronic  mania  of  an  extremely  bad  type, 
with,  as  I  thought,  many  of  the  signs  of  dementia.  I  had 
shown  her  to  my  clinical  class  on  several  occasions  as  a 
typical  case  of  chronic  mania.  The  chances  of  recovery  are 
in  inverse  ratio  to  the  length  of  the  disease  after  the  first  two 
years.  After  five  years  recovery  is  the  rare  exception,  but  I 
have  known  it  take  place  after  even  twenty  years. 

Epheraeral  Mania  {Mania  Transituria). — This  term  is  used 
to  describe  a  somewhat  rare  form  of  maniacal  exaltation, 
which  comes  on  suddenly,  is  usually  sharp  in  its  character, 
and  accompanied  by  incoherence,  partial  or  complete  uncon- 
sciousness of  famUiar  surroundings,  and  sleeplessness.  An 
attack  may  last  from  an  hour  up  to  a  few  days.  I  was  once 
called  in  to  see  a  young  man  in  Carhsle,  C.  Z.,  a  patient  of 
the  late  Mr  Robert  Brown,  who  suddenly,  without  premoni- 
tory symptoms  and  without  any  apparent  cause,  had  in  the 
afternoon,  in  the  midst  of  his  work,  become  incoherent  in  his 
speech,    talking    continuously,    restless,    pushing    about   the 


STATES   OF   MENTAL    EXALTATION.  205 

furniture,  did  not  know  his  relations,  and  expressed  many 
fleeting  unconnected  delusions.  He  was  not  very  violent  or 
difficult  to  manage.  He  would  take  no  food  or  medicine, 
and  there  was  no  means  of  making  him  do  so,  and  no  warm 
bath  to  be  got,  so  he  was  left  alone  under  the  charge  of  an 
attendant.  He  did  not  sleep  that  night,  but  towards  morning 
he  became  less  talkative  and  restless,  he  began  to  know  those 
about  him,  then  there  was  an  hour  or  two  of  stupidity,  con- 
fusion, and  lethargy,  and  next  day  by  mid-day  he  was  himself 
again,  went  to  his  work,  and  had  no  relapse.  That  was  the 
first  case  of  the  kind  I  had  ever  seen,  and  it  was  very  in- 
structive to  me,  for  I  always  since  ask  myself,  when  called 
in  to  any  suddenly  occurring  case  of  mania — Is  it  a  case  of 
mania  transitoria  ?  Since  then  I  have  met  with  many  some- 
what similar  cases,  both  among  patients  who  were  convalescent 
in  the  Asylum,  especially  among  epileptics,  and  also  in  patients 
who  were  not  in  the  Asylum.  I  think  cases  of  mania 
transitoria  result  from  the  following  causes.  Most  of  them 
are  epileptiform,  are,  in  fact,  of  the  nature  of  the  mental 
epilepsy  of  Hughlings  Jackson,  in  cases  where  distinct  motor 
epilepsy  does  not  exist.  I  believe  the  case  of  C.  Z.  was  of 
this  character.  Others  are  examples  of  the  ejnlepsie  larvee  of 
Morel, — masked  epilepsy,  where  a  mental  explosion  takes 
place  instead  of  an  ordinary  epileptic  fit. ,  A  few  of  the  cases 
result  in  young  persons  from  slight  moral  or  physical  causes, 
upsetting  brains  of  intense  instability  that  have  a  strong 
neurotic  heredity.  There  are  some  sxich  brains  so  easily  upset 
that  a  gust  of  passion,  a  sudden  stoppage  of  menstruation,  a 
slight  excess  of  alcohol,  of  sexual  intercourse,  or  of  masturba- 
tion will  make  them  delirious,  and  this  may  only  last  for  a 
short  time.  All  the  symptoms  of  mania  transitoria  may  be 
seen  in  the  incubation  of  and  during  febrile  and  inflammatory 
complaints,  such  as  scarlet  fever,  typhus,  and  typhoid,  local 
inflammations,  influenza,  &c.,  in  unstable  brains  that  are  upset 
by  very  little,  through  a  process  of  what  the  olden  authors 
called  metastasis.     I  have  seen  ephemeral  mania  after  ery- 


206  STATES  OF  MENTAL  EXALTATION. 

sipelas.  After  the  dynamite  explosion  in  January  1885  in 
London,  tlie  policeman  Cox  was  first  unconscious  and  then 
maniacal  and  deaf  for  a  few  hours. 

The  great  question  in  regard  to  ephemeral  mania  is  this — 
Can  we  tell  it  by  any  special  symptoms?  There  are  no 
definite  symptoms  that  I  know  by  which  we  can  tell  that  any 
maniacal  attack  is  going  to  be  ephemeral.  There  is  always  a 
presumption  that  when  an  attack  begins  very  suddenly  it  may 
end  suddenly,  and  if  such  an  attack  occurs  in  a  young  subject 
with  strong  heredity  to  insanity,  whose  diathesis  has  been 
very  neurotic,  and  whose  brain  has  manifested  unstable 
tendencies,  it  is  right  to  keep  tliis  form  of  mania  in  mind,  and 
not  be  in  too  great  a  hurry  in  sending  such  a  case  to  an  asylum. 
The  treatment  is  the  same  as  that  I  have  recommended  for 
acute  mania,  only  the  bromides,  sulphonal,  hyoscine,  and  cold 
apphcations  to  the  head  are  especially  indicated.  I  imagine  that 
family  doctors  who  attend  many  nervous  farm' lies  could  tell  of 
attacks  of  what  are  really  ephemeral  mania,  but  are  naturally 
called  by  all  sorts  of  euphemisms, — "  nervous  attacks," 
"  hysterical  attacks,"  &c.  I  once  saw  an  attack  of  ephemeral 
mania  come  on  and  last  a  few  hours  in  a  girl  who  had  usually 
exliibited  her  neurosis  by  attacks  of  hysteria. 

Homicidal  Mania. — In  popular,  and  sometimes  in  medical 
phraseology,  "  homicidal  mania  "  means  any  kind  of  mental 
disease  where  there  is  an  attempt  or  desire  on  the  part  of 
a  patient  to  kill.  But,  as  you  have  seen,  the  homicidal  desire 
may  occur  in  melanchoha,  and  is  often  associated  with  the 
suicidal  f  eehng.  As  we  shall  see,  it  may  occur  as  an  uncom- 
plicated impulse,  not  accompanied  by  depression  or  exaltation 
of  mind,  and  it  then  stands  as  one  of  the  varieties  of  impulsive 
insanity.  Eut  at  present  we  are  to  vieAV  it  as  one  of  the  chief 
symptoms  of  certain  forms  of  maniacal  exaltation.  In  tliis  it 
occurs  in  four  forms : — First,  and  most  commonly,  from  delu- 
sion, e.g.,  that  persons  attacked  are  persecuting  the  patient,  or 
are  going  to  kill  him.  Second,  from  sheer  excess  of  motor 
energy,  which  vents  itself,  as  it  were,  in  killing,  as  it  does 


STATES   OF  MENTAL  EXALTATION.  207 

more  ordinarily  in  smashing,  fighting,  or  tearing.  Third, 
from  a  distinct  morbid  desire,  impulse,  and  craving  to  kill. 
Fourth,  homicidal  attacks  are  made  in  the  unconscious 
delirium  of  acute  mania  without  "motive,"  without  "intent." 
Of  the  first  kind  was  the  case  of  C.  ]N^.  (p.  187),  when  she 
attacked  the  attendant,  on  admission,  under  the  delusion  that 
she  was  her  enemy  and  going  to  injure  her,  and  also  the 
following  cases. 

A  RemarJcahle  Case  of  Homicidal  Mania. — We  had  in 
Morningside  Asylum,  when  I  was  an  assistant  physician  there 
in  1860,  a  remarkable  case  of  homicidal  mania,  a  most  graphic 
account  of  which  was  published  by  my  friend  and  then 
colleague,  Dr  Yellowlees.^  The  man's  name  was  Willie 
Smith,  who,  beginning  with  an  attack  of  what  was  evidently 
simple  mania  in  1829,  and  taking  to  publishing  his  own 
effusions,  wrote  thus  : — 

"  There's  Willie  Smith,  the  carpenter, 
Become  at  last  a  publisher  ; 
You'll  find  his  works  in  rhyme  and  prose 
Throughout  this  land  o'  cakes  and  brose  ;  " 

and  because  his  contemporaries  laughed  at  him,  and  the  boys 

called   him    "  Whisker  Wilhe,"   broke   his   glass,  and  blew 

"smoke  out  of  a  horn  full  of  lighted  tow  into  my  shop,"  he 

applied  to  the  law.     And,  by  the  way,  what  a  psychological 

study  is   the   boy's   instinct   in   finding   out  weak  points  of 

inhibition,    his   altogether   uncontrollable   impulse   to   probe 

them   when   found,    and   his   delight    at   the   result !      The 

magistrates  would  give  Willie  no  redress.     Because  of  these 

things  he  imagined  ^e  was  persecuted,  and  planned  to  execute 

revenge  all  the  rest  of  the  thirty-two  years  of  his  life.     He 

was  a  perfect   example   of   French   megalomania, — elevated 

ideas  about  himself  and  his  powers,  combined  with  ideas  of 

persecution, — and,  in   addition,  with   strong   and    persistent 

homicidal  tendencies.     With   loaded   guns,    daggers,  spears, 

axes,  swords,  extemporised  weapons  of  all  sorts,  he  meditated 

^  Edin.  Med.  Jour.,  August  1862. 


208  STATES   OF   MENTAL   EXALTATION. 

and  tried  revenge  and  homicide.  In  the  gaol,  the  poorhonse, 
the  Asylum,  he  made  repeated,  persistent,  and  numerous 
attempts  to  murder  attendants  and  physicians,  and  was  the 
terror  of  all  who  knew  him.  "It  is  scarcely  possible  to  find 
language  strong  enough  to  describe  the  bloodthirsty  passion 
which  possessed  the  man,  the  devilish  intensity,  dehberation, 
and  determination  with  which  all  his  attacks  were  made,  or 
the  fiendish  delight  with  which  he  gloried  in  relating  them." 
Yet  all  the  time  he  had  "  exaltation  of  the  feehng  of  pride,  and 
high  ideas,  and  delusions  regarding  his  own  powers  and  capa- 
bihties,  particularly  as  an  engineer,  architect,  and  musician." 
A  visit  to  him  was  the  sight  of  the  Asylum,  and  a  tiling  to 
be  remembered  for  many  years.  I  do  not  know  how  it  is,  but 
such  picturesque  cases  of  insane  would-be  murderers  do  not 
seem  to  occur  now.  The  fewer  precautions  that  are  taken, 
the  less  need  there  seems  to  be  for  them. — When  he  died  his 
head  was  found  to  have  undergone  great  changes  in  shape,  as 
compared  with  a  cast  taken  twenty  years  before,  and  his 
brain  was  much  atrophied. 

Homicidal  Act  the  First  Symptom  of  Mania. — I  had  a 
patient  once,  C.  Z.  A.,  set.  about  28,  with  a  strong  heredity 
towards  mental  disease,  who  had  been  working  too  hard  at 
brain  work  that  was  uncongenial  to  him,  had  also  had  a 
disappointment,  and  who  had  previously  shown  only  a  little 
mental  confusion  for  a  week,  when  suddenly,  without  warning, 
he  made  a  homicidal  attack  on  his  brother  when  taking  a 
walk,  under  the  delusion  that  his  brother  wanted  to  do  him 
harm.  This  was  really  the  first  distinct  symptom  of  an  attack 
of  subacute  mania.  There  were  strong  reasons  why  he  should 
not  be  sent  to  any  asylum,  and  I  got  a  first-rate  attendant  for 
him,  who  kept  him  out  in  the  open  air,  walking,  fishing,  &c., 
for  ten  hours  a  day.  I  put  him  on  milk  diet,  with  warm 
baths,  Parrish's  syrup,  occasional  draughts  of  bromide  of 
potassium  and  chloral  at  night,  and  used  occasional  blisters  to 
his  head.  He  used  often  to  attack  his  attendant  from 
delusions  about  liim,  who,  however,  never  lost  his  nerve  and 


STATES   OF   MENTAL   EXALTATION.  209 

was  not  afraid  of  him.  He  always  apologised  afterwards. 
Gradually  the  excitement  passed  off,  and  in  about  eight 
months  he  recovered.  A  certain  mental  irresolution  and 
tendency  to  change  was  the  last  symptom  to  disappear,  as  is 
the  case  commonly  in  mental  disease.  A  full  power  of 
vohtion,  spontaneity,  the  power  to  originate,  are,  in  fact,  the 
highest  mental  faculties,  and  are  the  last  to  return  and  the 
most  apt  to  be  left  impaired.  I  could  scarcely  have  believed 
at  one  time  that  such  a  patient  as  C.  Z.  A.  could  possibly  or 
safely  be  treated  out  of  an  asylum. 

The  second  kind  of  maniacal  homicidal  attack,  viz.,  that 
from  sheer  excess  of  motor  energy,  is  often  seen  both  in 
acute  and  chronic  cases.  We  had  a  young  man,  C.  Z.  B.,  in 
the  Asylum,  who,  when  he  first  became  insane,  attacked  a 
man  on  the  street,  and  got  his  own  eye  knocked  out,  and  for 
many  years  did  little  by  night  and  day  but  groan  and  shout 
in  crescendo  movement,  box  the  walls  so  that  his  hands  and 
knuckles  were  hard  as  horns,  swollen,  and  often  cut.  He 
would  often  attack  patients  and  attendants  and  officials 
violently.  He  was  wonderfully  rational  amidst  all  this, 
saying  he  could  not  help  it,  that  the  steam  would  out,  and 
that  he  had  no  desire  to  hurt  any  one  or  any  feeling  of 
revenge  against  any  one.  I  have  now  a  lady  who  is  subject 
to  paroxysms  of  acute  mania,  during  which  she  screams  in  an 
Unearthly  howl,  tears'  her  clothes,  bites  her  own  hands,  and 
will,  if  you  will  allow  her,  take  your  hand  into  her  mouth  and 
bite  it  a  little  all  round  without  really  hurting  you. 

The  third  form,  that,  namely,  resulting  from  a  distinct 
morbid  impulse  to  kill,  without  conscious  motive,  I  shall 
treat  of  more  fully  under  impulsive  insanity,  the  homicidal 
variety  of  which  it  is,  with  maniacal  exaltation  superadded. 

The  fourth,  or  merely  delirious  form,  is  not  really  very 
dangerous,  because  it  is  purposeless  and  aimless,  and  the 
violence  is  not  co-ordinated.  It  seldom  is  seen  except  when 
delirious  patients  are  unduly  controlled.  A  physician  or  a 
good  attendant  in  an  asylum  generally  walks  up  to  a  maniacal 

o 


210  STATES   OF   MENTAL  EXALTATION. 

patient  quite  unconcernedly  as  to  danger,  thinking  only  of 
the  symptoms  present,  just  as  one  would  going  in  to  see  a 
case  of  pneumonia. 

Prevalence  of  Mania. — The  relative  prevalence  of  conditions 
of  mental  exaltation  is  brought  out  by  the  fact  that  out  of 
2377  cases  admitted  into  the  Eoyal  Edinburgh  Asylum  in  the 
seven  years  1874-80,  1310,  or  55  per  cent.,  were  classified 
as  mania,  while  only  729,  or  36  per  cent.,  were  cases  of 
melanchoHa.  The  relative  prevalence  of  the  two  conditions 
I  have  shown  in  Plate  V.,  which  also  shows  the  ages  at 
which  they  occur.  Mental  exaltation  is  there  seen  to  prevail 
more  at  earlier  ages  than  depression,  and  to  occur  most  at  two 
periods,  viz.,  at  the  end  of  adolescence,  and  then  about  ten 
years  afterwards. 

Insane  Delusions  in  Mania. — The  most  important  thing  to 
ascertain  about  delusions  in  mania  is  whether  they  are  "fixed" 
or  fleeting.  A  fixed  delusion  is  usually  the  concentrated  ex- 
pression of  a  delusional  condition  of  mind.  I  mean  that  it  is 
seldom  a  patient,  e.g.,  has  merely  the  one  delusion  that  a  person 
works  an  electric  battery  to  annoy  him.  Such  a  delusion  is 
generally  the  expression  of  an  organic  or  nervous  sensation 
of  discomfort  or  pain,  which  makes  him  have  his  natural 
suspicions  heightened,  he  being  morbid  also  on  other  points. 
He  wiU  not  trust  any  one.  He  is  apt  to  think  the  air  of  liis 
room  or  his  food  is  poisoned.  If  the  person  whom  he 
beheves  to  be  working  this  battery  goes  away,  he  will  soon 
fix  in  his  morbid  imagination  the  same  thing  on  another. 
A  patient  usually  not  only  beheves  himself  to  be  a  king,  but 
his  whole  state  of  mind  is  that  of  delusive  grandeur.  Such 
fixed  delusional  states,  that  last  for  more  than  a  few  months, 
in  mania,  are  unfavourable  as  to  prognosis ;  but  do  not  put 
down  either  a  single  delusive  fancy  that  is  repeated  con- 
sistently a  few  hundred  times,  or  a  delusive  condition  that 
merely  lasts  a  few  weeks,  as  a  fixed  delusion.  The  fixity  of 
a  delusion  depends  on  two  things,  the  hold  it  has — whether 
it  dominates  the  mental  life — and  the    time   it  has  existed. 


STATES   OF   MENTAL   EXALTATION.  211 

Fleeting  delusions  are  most  typically  seen  in  that  delirium 
where  nothing  that  is  said  has  any  relation  to  facts,  and 
where  no  fancy  nor  untrue  statement  is  repeated  often. 
In  very  many  cases  of  mania  a  delusion  persists  for  a  few 
months  or  longer,  and  yet  passes  away,  and  should  not  be 
counted  a  fixed  delusion.  There  is  no  doubt,  however,  that 
the  less  fixed  and  the  more  fleeting  a  delusion  is,  the  better 
is  the  prognosis. 

Delusions  take  innumerable  forms  in  mania.  One  of  the 
most  common  forms  is  mistaking  the  identity  of  persons, 
calhng  them  by  wrong  names,  and  recognising  old  friends  in 
persons  never  seen  before.  Certain  kinds  of  insanity,  such  as 
the  puerperal  form,  are  specially  characterised  by  this  sort  of 
delusion. 

Emotional  Conditions  in  Mania. — Dr  G.  M.  Eobertson^ 
has  pointed  out  that  the  cases  of  mania  divide  themselves 
into  two  varieties  when  looked  at  from  the  emotional  point  of 
view.  In  the  one  class  the  prevailing  emotions  are  those  of 
pleasure  and  joy, — hilarious  mania;  while  in  the  other  the 
prevailing  emotions  are  rage  and  anger, — furious  mania.  The 
facial  expressions,  gesticulations,  and  delusions  are  very 
different  in  the  two.  But  the  same  case  may  change  from  joy 
to  rage,  and  vice  versa. 

Indications  of  Prognosis  in  Mania. — The  following  are  in 
my  experience  favourable  indications  in  prognosis : — A  sudden 
onset  of  the  disease ;  very  acute  symptoms  coming  on  soon ;  a 
short  duration ;  youth  of  the  patient ;  no  fixed  delusions  nor 
delusional  conditions ;  appetite  for  food  not  quite  lost ;  no 
positive  revulsion  against  nor  perversions  of  the  food  and  drink 
appetites ;  no  indication  of  enf eeblement  of  mind ;  no  paralysis 
nor  paresis,  nor  marked  aff'ection  of  the  pupils ;  no  epileptic 
tendency;  no  complete  obliteration  nor  alteration  of  the 
natural  expression  of  the  face  or  eyes;  the  instincts  of 
delicacy  and  cleanliness  not  quite  lost ;  no  unconsciousness  to 
the  calls  of  nature ;  the  articulation  not  affected ;  the  disease 
^  Journal  of  Mental  Science,  iSxxiy  \?,QQ. 


212  STATES   OF   MENTAL  EXALTATION. 

rising  to  an  acme  and  then  showing  slow  and  steady  signs  of 
receding;  no  former  attacks,  or  only  one  or  two  that  have 
been  recovered  from. 

The  effect  of  a  strong  and  direct  hereditary  predisposition 
is  not,  as  is  commonly  believed,  sufficient  to  lessen  the  chances 
of  recovery,  especially  in  the  first  attack.  On  the  con- 
trary, hereditary  cases  are  often  very  curable,  but  relapses 
are  more  probable.  A  brain  so  predisposed  is  more  readily 
upset  by  shght  causes. 

The  following  are  unfavourable  indications  in  prognosis  : — 
A  gradual  and  slow  onset,  as  if  it  were  an  evolution  of  an 
innate  bad  brain  tendency, — e.g.,  if  a  naturally  suspicious 
man  has  gradually  become  insanely  and  delusionally  suspicious, 
OT  a  naturally  vain  man  has  become  affected  with  insane 
delusions  of  grandeur;  great  length  of  duration  of  the 
attack,  such  as  twelve  months'  persistence  of  fixed  delusions 
or  delusional  states  and  especially  of  hallucinations ;  extreme 
and  increasing  exhaustion  of  the  patient  in  spite  of  proper 
treatment ;  paralysis  of  the  trophic  power,  so  that  his  body 
nutrition  cannot  be  restored ;  persistent  refusal  of  food, 
requiring  forcible  feeding ;  extreme  failure  of  the  cardiac 
action  and  circulation,  so  that  the  extremities  are  always 
blue  and  cold;  persistent  affections  of  the  pupils,  especially 
extreme  contraction ;  persistently  dirty  habits ;  a  tendency 
towards  dementia ;  a  tendency  towards  chronic  mania ;  an 
utter  and  persistent  deterioration  in  the  facial  expression, 
especially  if  it  be  towards  vacuity  ;  persistent  and  complete 
paralysis  or  perversion  or  degradation  of  the  natural  affections, 
tastes,  habits,  and  appetites ;  many  former  attacks ;  convulsive, 
paretic,  paralytic,  jox  inco-ordinative  symptoms ;  such  per- 
verted sensations  and  locahsed  trophic  disturbances  as  cause 
patiefits  to  pick  the  skin,  pull  out  the  hair,  bite  off  the  nails 
into  the  quick ;  marked  changes  in  the  skin,  hair,  and  secretions 
long  continued ;  a  restoration  of  sleep  and  bodily  nutrition, 
without  in  due  time  an  improvement  mentally ;  very  per- 
sistent insane  masturbation  ;  a  tendency  for  the  exaltation  to 


STATES   OF  MENTAL  EXALTATION.  213 

pass  off,  and  fixed  delusion  to  take  its  place;  excitation  of 
the  Kmbs  and  subsnltus  tendinum  ;  a  "  typhoid  "  condition. 

Termination  of  Mania. — There  may  be  said  to  be  five  usual 
terminations.  1.  Complete  recovery ;  this  takes  place  in 
about  half  of  all  the  cases  of  mania.  2.  Partial  recovery,  the 
patient  becoming  rational  and  fit  for  work,  but  with  a  change 
of  character  or  affection,  or  an  eccentricity,  or  slight  mental 
weakness,  or  want  of  mental  inhibition,  or  lack  of  fixity  of 
purpose,  or  a  partial  paralysis  of  the  social  instincts,  or  some 
inabihty  to  get  on  with  people,  or  a  lack  of  or  lessening  of 
some  mental  quality  wliich  the  patient  possessed  before.  This 
is  unfortunately  a  by  no  means  uncommon  result  of  an  attack 
of  any  kind  of  insanity,  but  more  especially  of  an  attack  of 
mania.  Such  persons  count  often  among  the  recoveries,  and 
are  reckoned  legally  sane.  It  is  quite  impossible  to  find  out 
how  many  such  cases  there  are,  but  I  fear  that  at  least  one- 
third  of  all  those  who  "  recover "  exhibit  some  such  mental 
change  as  compared  with  their  former  sane  selves.  I  think 
it  is  of  the  utmost  importance  to  have  the  cure  completed, 
therefore,  if  possible,  by  prolonged  medical  care,  by  getting 
the  whole  bodily  state,  in  regard  to  nutrition  and  nourish- 
ment, up  to  the  highest  possible  mark  before  a  patient  returns 
to  work  or  subjects  himself  to  the  causes  of  a  relapse.  It 
is  the  existence  so  often  of  this  condition  of  mental  change 
or  mental  twist,  and  the  habihty  to  relapse,  that  makes  the 
public  suspicious  of  a  man  who  has  been  insane ;  through 
which  suspicion  great  hardship  and  injustice  are  often  done  to 
those  who  have  already  suffered  from  one  of  the  most  terrible 
of  human  diseases.  3.  The  substitution  of  fixed  delusions  or 
delusional  states  (monomania)  for  the  exaltation  as  the  latter 
passes  off.  It  is  difficult  to  find  out  statistically  how  often 
this  occurs.  The  patients  may  live  long  when  this  takes  place, 
except  the  delusional  condition  be  that  of  morbid  suspicion,  in 
which  case  they  will  probably  die  of  phthisis  within  a  few 
years.  4.  Dementia  supervenes.  This  happens  in  about  30 
per  cent,  of  the  cases  of  mania  generally.     It  is  the  event  we 


214  STATES   OF  MENTAL  EXALTATIOl?. 

most  dread.  It  is  equivalent  to  a  mental  death,  while  the 
body  may  Kve  for  many  years,  especially  if  the  dementia  has 
come  on  in  youth.  We  have  had  many  patients  Hve  so  for 
fifty  years  in  Morningside.  The  bulk  of  the  chronic  patients 
in  asylums  are  of  this  class.  5,  Death  occurs  in  about  five 
per  cent,  of  the  cases  from  exhaustion,  or  from  causes  directly 
traceable  to  the  disease. 

It  must  be  understood  that  those  are  the  terminations  in 
cases  of  mania  so  severe  as  to  require  asylum  treatment.  If 
we  could  include  the  slighter  cases  treated  at  home,  the 
recoveries  would  be  more  and  the  terminations  in  dementia 
and  death  fewer. 

Prophylaxis  of  Mania. — A  very  important  question  often 
needs  solution  by  medical  men  in  practice.  There  are  young 
people  growing  up  in  the  famihes  they  attend  with  neurotic 
heredity,  with  manifestly  unstable  brain  constitution,  with 
"  excitable "  dispositions  and  nervous  diathesis ;  and  the 
all-important  question  is  asked — How  can  such  persons  best 
avoid  the  tendency  to  attacks  of  mania  1  They  have  patients 
who  have  already  had  attacks  of  maniacal  exaltation,  some 
decided  and  some  only  nascent — How  can  those  be  avoided  in 
the  future  ?  If  our  present  knowledge  enabled  us  to  answer 
these  questions,  no  doubt  there  would  be  less  insanity  in  the 
world  than  there  is.  "We  cannot  do  so  surely,  but  we  can  do 
something  in  the  direction  of  lessening  the  tendency  of  a 
brain  to  mania,  I  have  no  doubt.  Beyond  question,  persons 
with  this  brain  constitution  should  not  enter  on  exciting  and 
hazardous  occupations.  To  take  extreme  examples,  they 
should  not  be  stockbrokers,  election  agents,  or  speculators. 
Quiet  routine  modes  of  hfe  suit  them  best;  positions  with 
fixed  work  and  fixed  salaries  are  most  desirable  for  them. 
Much  outdoor  life,  hving  according  to  rule,  dividing  up  their 
day  into  regular  portions  for  work  and  idleness  and  amuse- 
ment. As  regards  diet,  the  same  advice  I  gave  about  children 
predisposed  to  melancholia  appHes  here.  It  should  consist 
largely  of  milk  and  farinaceous  diet  for  the  young.     I  lately 


STATES  OF  MENTAL   EXALTATION.  215 

saw  a  very  excitable  boy  of  six,  very  thin,  restless,  not  sleeping 
much,  and,  of  course,  very  bright  and  quick  for  his  age.  I 
found  he  was  getting  animal  food  three  times  a  day,  and  his 
guardians  deplored  the  fact  that  he  could  not  take  milk ;  my 
advice  was  to  starve  him  into  taking  it,  to  make  him  walk 
much  and  keep  him  out,  and  give  him  when  he  came  in  only 
bread  and  milk.  Of  course  it  was  disagreeable  at  first,  but 
the  boy  soon  acquired  an  appetite  for  such  food,  his  bodily 
conformation  largely  changed,  and  he  got  fatter,  less  active, 
less  nervous,  and  slept  far  more.  Children  Avith  this  disposi- 
tion are  nearly  always  flesh-eaters,  and  I  have  sometimes  found 
them  fed  on  beef-steaks  and  port  Avine,  with  strong  beef-tea 
between  meals !  I  look  on  strong  beef -tea  drunk  alone,  with- 
out bread  or  potatoes,  as  simple  poison  for  such  children.  I 
do  not  of  course  mean  this  to  apply  when  they  are  ill,  and 
need  a  stimulant.  Such  persons  should  take  as  much  sleep  as 
possible  j  they  should  cultivate  quiet  hobbies ;  they  should 
select  country  occupations,  and  avoid  stimulants,  tobacco,  and 
sexual  intercourse  till  after  adolescence.  While  ordinary  well- 
constituted  brains  may  stand  moderate  excesses  of  all  kinds,  in 
work  and  in  pleasure,  and  may  even  in  a  way  be  said  to  be 
sometimes  the  better  for  them  if  not  too  often  repeated,  this  is 
unquestionably  not  the  case  with  those  I  am  now  describing. 
The  excess  of  power  beyond  the  daily  needs,  the  capacity  of 
quick  recuperation,  the  tendency  to  stop  working  and  to  sleep 
when  tired,  the  power  of  being  satisfied  with  only  a  slight 
or  an  occasional  excess  over  what  the  strict  laws  of  nature 
would  dictate,  which  characterise  healthy  well-constituted 
brains,  are  all  wanting  in  those  predisposed  to  maniacal 
attacks.  I  cannot  help  thinking  that  for  such  persons  to  take 
to  study  or  to  occupations  that  imply  much  brain-Avork  is  a 
risk,  though  they  have  often  bright  intellects.  It  seems  to 
me  as  if,  instead  of  that,  they  should  go  back  to  nature  and 
mother  earth,  and  become  farmers  and  colonists.  I  once  knew 
two  brothers,  twins,  alike  in  mind  and  body,  who  had  a  strong 
heredity  to  mania.     They  both  became  medical  students,  and 


216  STATES   OF   MENTAL  EXALTATION. 

one  had  an  attack  of  acute  mania  at  twenty,  which  ended  in 
dementia.  At  the  beginning  of  his  brother's  attack- the  other 
had  distinct  premonitions  of  the  same  disease — was  sleepless, 
restless,  unsettled,  had  queer  sensations  in  his  head,  and  felt  as 
if  he  would  lose  his  self-control.  But  he  at  once  fled,  as  for 
his  life,  from  books  and  brain-work,  and  went  to  be  a  land-sur- 
veyor in  the  Ear  West.  His  neurotic  symptoms  passed  off,  and 
he  grew  into  a  strong  and  happy  man.  I  think  it  is  the  instinct 
of  mental  self-preservation  that  makes  young  men  sometimes 
fly  from  the  influences  of  civilisation  and  take  to  the  backwoods, 
the  "Planomania"  of  some  authors.  But  what  about  young 
women  1 .  Alas !  the  prospect  for  them  with  such  heredity, 
and  particularly  when  they  are  well  off  and  live  in  cities,  is 
often  lamentable.  So  far  as  my  experience  and  observation 
go,  the  regulated  hfe  of  a  convent  or  sisterhood,  or  systematic 
religious  and  philanthropic  work,  fulfil  the  conditions  of 
prophylaxis,  when  the  tendency  is  very  strong,  better  than 
anything  else.  I  am  often  profoundly  impressed  with  the 
physiological  and  medico-psychological  character  of  many  of 
the  observances  and  regulations  of  the  Eoman  CathoHc  Church 
as  to  modes  of  life  and  outlets  for  the  emotions.  The  framers 
of  these  observances  had  often  anticipated  modern  physiological 
inductions. 

But  suppose  there  is  not  merely  a  predisposition,  but  that 
the  actual  prodromata  of  the  disease  are  showing  themselves, 
let  us  say  sleeplessness,  want  of  full  power  of  self-control,  and 
general  unsettledness,  should  medicinal  hypnotics  be  taken — 
opium  or  bromides,  paraldehyde,  sulphonal  or  chloral,  or  hen- 
bane? I  think  I  have  seen  these  do  more  good  as  sleep- 
producing  prophylactics  than  as  curatives  after  the  disease  had 
actually  begun.  There  is  no  doubt  that  in  the  matter  of  its 
rest-in-sleep  power,  Hke  many  of  its  other  faculties,  the  brain 
forms  habits,  and  gets  into  bad  and  morbid  as  well  as  into 
good  habits.  A  man  falls  off  his  sleep  at  his  regular  time  or 
awakes  at  too  early  an  hour,  and  he  cannot  get  rid  of  this 
habit  his  brain  has  got  or  is  getting  into,  and  if  allowed  to  go 


STATES   OF  MENTAL  EXALTATION.  217 

on  uncorrected  he  will  become  exhausted  and  insane.  Now, 
while  I  should  in  such  a  case  invariably  try  first  nature's  simple 
sedatives — sea  or  mountain  air  breathed  all  day,  muscular 
fatigue,  hot  drinks  at  bed  time,  warm  baths,  cold  or  hot  to  the 
head  or  feet  experimentally  before  going  to  bed,  change  of 
scene  and  work,  &c.,  yet  I  have  to  aid  these  often  by  a  few 
doses  of  paraldehyde,  sulphonal  or  chloral,  and  the  bromides, 
or  even  by  a  grain  or  two  of  opium  at  night.  Camphor  and 
tincture  of  lupuline  are  often  sufficient  sedatives,  or  a  few  drops 
of  tincture  of  belladonna, — in  fact,  any  sleep-producer.  But 
do  not,  if  possible,  let  the  brain  get  into  the  evil  habit  of 
depending  on  such  drugs  for  sleep. 


LECTURE   V. 

STATES  OF  ALTEEXATIO^,  PERIODICITY,  REMIS- 
SION" Am)  RELAPSE  m  MENTAL  DISEASES 
{FOLIE  CIRCULAIRE  PSYCHOREYTHM,  FOLIE 
A  DOUBLE  FORME,  CIRCULAR  INSANITY, 
PERIODIC  MANIA,  RECURRENT  MANIA, 
KATATONIA). 

Physiological  alternations  and  periodicity;  the  law  of  "action  and 
reaction  " — Reproductive  and  sexual  periodicity,  with  their  mental 
changes  of  periodic  elevations,  perversions,  irritabilities  ;  the  perio- 
dicity of  neuralgia,  epilepsy,  sleeplessness,  &c. — Folie  Circulaire  a 
distinct  disease  ;  first  described  by  Falret  and  Baillarger  ;  three 
conditions  in  the  circuit ;  depression,  exaltation,  and  comparative 
sauity — Duration  of  these  varies  in  different  cases  ;  a  very  incurable- 
disease — Psychological  interest  of  this  disease  ;  the  same  brain  in 
different  states ;  other  symptoms  periodic  too,  e.g.,  cephalalgia, 
vomiting,  &c. — A  few  relapses  iu  mania  or  melancholia  do  not  con- 
stitute this  disease — Treatviervt :  complete  the  cure  in  all  insanity  in 
youth  and  adolescent  insanity — prevent  a  "brain  habit"  being 
formed,  or  a  "vicious  circle"  being  got  into  ;  the  bromides  ;  non- 
stimulating  diet ;  marriage,  exercise,  regimen  —  Heredity  the 
strongest  predisposing  cause  ;  good  brains  ;  old  families — Relapse 
or  Periodicity  occur  in  most  forms  of  mental  disease ;  from  40  to  50 
per  cent,  of  all  the  cases ;  most  common  in  youth  and  in  the  female 
sex,  and  in  hereditary  cases ;  prepare  minds  of  relatives  for  relapses ; 
counsel  prolonged  rest  or  control  in  relapsing  cases  before  work 
resumed  ;  get  health,  fatness,  and  dynamical  equilibrium  of  brain 
thoroughly  established. 

Physiological  Periodicity. — One  of  the  most  fundamental  of 
the  laws  that  govern  the  higher  functions  of  the  nervous 
centres  in  all  vertebrates  is  that  of  alternation  and  periodicity 
of  activity  and  inactivity.     In  all  the  higher  species  of  the 


STATES   OF   MENTAL  ALTERNATION.  219 

class  the  periods  of  inactivity — sleep — are  marked  by  un- 
consciousness, and  are  often  combined  witli  the  mental 
phenomena  of  dreaming  and  muscular  expressions  or  equiva- 
lents of  ideation ;  which  things  are  quite  as  strange  and 
inexplicable  in  their  essential  nature  as  the  phenomena  of 
mental  disease.  Both  may  be  in  a  general  way  understood 
by  reference  to  mentalisation  as  a  brain  function.  IS'either 
are  in  any  way  comprehensible  on  any  mere  mind  theory 
apart  from  brain.  The  sleep  and  waking  periodicity  of  the 
higher  brain  functions  is  the  foundation  and  type  of  all  the 
other  periodicities  which  exist  in  nervous  action,  and  they  are 
not  a  few.  The  yearly  hibernation  of  many  animals,  the 
daily  periodic  rises  and  falls  of  body  temperature,  the  daily 
increase  and  decrease  of  the  pulsations  of  the  heart  and  of  the 
cardiac  pressure,  the  periodic  returns  of  the  appetites  for  food 
and  drink,  and  of  the  activities  of  the  glands  and  involuntary 
muscles  through  which  food  is  digested  and  assimilated,  are 
all  examples  of  secondary  nervous  periodicities  which  occur  in 
the  course  of  the  daily  life  of  the  organism.  "When  we  look 
at  the  function  of  reproduction  of  the  organism,  we  find  that 
its  every  activity  and  process  is  subject  to  laws  of  periodicity 
of  the  most  marked  character;  and  there  can  be  no  doubt 
that  these  all  have  their  origin  in  the  nervous  centres,  chiefly 
in  the  brain.  The  period  of  reproductive  activity  is  always, 
in  both  sexes,  the  period  of  greatest  physiological  mental 
exaltation.  The  periodic  rutting  season  in  male  animals,  with 
its  courage,  pride,  activity,  display,  pugnacity,  and  restless- 
ness ;  the  young-bearing  and  suckling  period  in  females,  with 
its  increased  courage,  skill,  cunning,  protective  and  providing 
instincts,  show  how  the  functions  of  the  brain  are  affected  by 
the  reproductive  periodicity.  So  much  are  they  affected  that 
the  mental  characteristics  of  some  animals  are  then  completely 
changed  from  their  natural  condition,  and  reversed,  the  timid 
becoming  bold  and  the  shy  obtrusive  ;  hereditary  and  natural 
antipathies  and  fears  disappear  for  the  time,  the  habits  change, 
night-feeders   become   day-feeders,   &c.     "We  should   not  ap- 


220  STATES   OF   MENTAL  ALTERNATIOX. 

proacli  the  study  of  the  periodicity  of  symptoms  in  nervous 
and  mental  diseases  without  keeping  in  mind  these  laws  and 
facts  of  the  physiological  periodicity  of  normal  nerve  function, 
wherever  we  have  a  higher  nervous  system. 

Looking  at  the  mental  activities  of  human  heings,  we  find 
them  strongly  influenced  by  the  physiological  periodicities. 
What  man  is  there  who  is  not  emotionally  more  elevated  or 
depressed,  more  active  or  inactive  in  mind  at  certain  times,  and 
at  his  periods  of  almost  regularly  recurring  reproductive  desire 
and  capacity?  What  woman  is  exactly  the  same  in  mind 
before,  during,  and  after  menstruation,  and  during  pregnancy 
or  lactation  ?  And  the  instant  we  pass  from  absolutely  healthy 
brains,  all  those  periodicities  count  for  more  in  the  mental 
life,  their  effect  in  dulling,  elevating,  and  depressing  being  far 
greater.  There  are  thousands  of  sane  men  and  women  who  are 
regularly  duller  in  the  morning  and  more  lively  in  the  evening, 
or  the  reverse;  or  who  are  duller  in  the  "winter  and  more 
elevated  in  the  summer ;  or  who  are  more  irritable — -that  is, 
have  diminished  inhibitory  power — at  periodic  intervals,  or 
who  are  subject  to  "moods,"  "cravings,"  and  "tempers" 
periodically.  There  are  many  persons  whose  mental  life  is  one 
long  alternation  of  "action"  and  "reaction,"  activity  and 
torpor,  by  a  natural  law  of  their  organisation.  When  we  look 
at  diseases  of  the  nervous  system  other  than  the  mental,  we 
find  many  of  them  often  markedly  periodic  in  their  symptoms 
and  times  of  recurrence.  I  need  only  instance  neuralgia, 
asthma,  megrim,  and,  above  all,  epilepsy,  that  motor  analogue 
of  many  mental  diseases. 

Folie  Girculaire. — Two  French  writers,  Falret  and  Bail- 
larger,  were  the  first  to  describe  as  a  special  form  of  insanity 
certain  cases  in  which  there  are  regularly  alternating  and 
recurring  periods  of  mental  exaltation,  depression,  and  sanity, 
and  to  call  it  folie  circulaire.  Each  of  these  periods  may 
vary  in  absolute  duration  from  a  day  to  several  years,  and  in 
relative  duration  to  the  other  conditions  in  the  circuit  in 
different  cases ;  but  they  always  recur  and  follow  each  other 


STATES   OF  MENTAL  ALTERNATION.  221 

with  more  or  less  regularity.  In  some  the  period  of  exaltation 
is  long  and  the  depression  and  sanity  short ;  in  others  this  is 
reversed.  But  in  the  really  typical  case  the  periods  are  each 
about  the  same  length  in  each  psychological  circle,  and  the 
recurring  circles  all  about  the  same  size.  Usually  there  is 
something  special  in  each  case  about  the  exaltation  and 
depression.  The  exaltation  is  commonly  very  pure  brain 
exaltation,  with  often  hypersesthesia  and  exaltation  of  many 
of  the  nervous  functions,  with  much  reasoning  power  left, 
but  little  self-control  or  common  sense,  the  lower  in  morality 
being  elevated,  the  higher  depressed,  the  condition  described 
by  the  French  as  folie  t^aisonnante,  or  Prichard's  moral 
insanity,  being  well  marked  in  the  early  stage.  There  is 
then  in  nearly  all  the  cases  great  increase  of  the  reproductive 
nisus.  The  phases  of  the  exaltation,  down  even  to  small 
things,  recur  regularly  in  different  attacks  at  the  same  time. 
The  depression  is  apt  to  be  characterised  by  apathy  and  torpor 
rather  than  by  intense  mental  pain :  there  are  seldom  any 
strong  suicidal  feelings  or  impulses,  though  to  this  there  are 
marked  exceptions.  And  the  period  of  sanity  is  apt  to  be  a 
sort  of  stupid,  inactive  sanity,  wanting  in  volitional  power, 
full  affectiveness,  and  spontaneity.  The  mental  balance'  goes 
on  oscillating  between  melancholia  and  mania,  standing  still 
at  the  happy  mean  of  apparent  sanity  just  long  enough  to  raise 
hopes  that  recovery  has  taken  place  for  a  few  times,  till  the 
nature  of  the  disease  is  apparent  to  the  physician,  and  as 
often  as  they  occur  to  ever-hoping  relatives.  It  is  mostly  an 
incurable  disease,  and  the  bad  cases  are  usually  sent  to  asylums 
rather  than  treated  at  home. 

The  interest  of  this  form  of  mental  disease  is  small  when  it 
is  merely  looked  at  as  a  rare  psychosis  of  typical  form ;  but  it  is 
very  great  indeed  to  the  student  of  psychiatry  when,  in  the 
first  place,  we  make  it  a  means  of  studying  the  clinical 
differences  in  the  whole  brain  and  body  state  of  the  same 
patient  in  exaltation,  depression,  and  sanity  respectively ;  and 
when,  in  the  second  place,  we  look  on  it  as  a  pathological 


222  STATES   OF  MENTAL  ALTERNATION. 

illustration  of  tlie  great  physiological  periodicities  to  which 
I  have  referred,  and  of  the  frequent  tendency  there  is  in 
nearly  all  cases  of  insanity,  or  at  least  in  most  of  those 
that  are  hereditary,  towards  relapse,  alternation,  periodicity, 
or  sympathy  with  exalted  physiological  function. 

The  following  are  some  illustrative  cases  of  folie  circulaire  : — 

D.  A.,  aet.  49  on  admission  to  Asylum.  He  had  never  been 
placed  in  a  hospital  for  the  insane  before,  though  he  had  had 
from  his  boyhood  dull  times  and  active  times,  and  many 
sHghter  attacks  of  the  kind  I  am  about  to  describe  for  five  or 
six  years  previous  to  his  admission.  In  one  of  the  periods  of 
exaltation,  while  holding  an  important  position  in  India,  he 
had  got  two  tiger  ciibs  and  tried  to  drive  them  in  harness 
through  the  streets  of  the  Eesidency.  His  education  was 
good,  his  temperament  sanguine.  He  had  been  reckoned 
proud  and  retiring,  and  he  was  of  an  old  and  distinguished 
family.  In  bodUy  conformation,  carriage,  and  bearing  he  was 
the  type  of  an  aristocrat.  A  paternal  uncle,  at  least,  had 
been  insane,  and  had  shown  periodicity.  His  family  had 
been  a  very  artistic  one,  but  he  had  never,  when  sane,  shown 
any  talent  in  that  way.     He  had  married  and  had  children. 

Just  before  admission  he  had  been  spending  money  reck- 
lessly, proposing  marriage  to  niany  suitable  and  unsuitable 
persons,  getting  into  passions  and  using  threats  about  trifles, 
reckless,  eccentric,  changeful  as  the  winds  in  intention  and 
■execution.  The  attack  was  coming  on,  but  had  not  come  to  a 
height  till  a  week  after  a  domestic  loss. 

When  admitted  he  was  much  excited  and  very  indignant, 
calling  on  all  to  witness  that  he  was  iQegally  imprisoned, 
threatening  the  dire  vengeance  of  the  law  on  all  who  had  to 
do  with  it,  but  in  about  ten  minutes  he  was  quite  jolly  and 
amusiug  himself  with  a  game  of  billiards.  At  first  he  was 
merely  exalted  mentally,  but  had  much  self-control.  His 
excitement  consisted  in  a  constant  restlessness,  a  perpetual 
twisting  movement  and  play  of  his  facial  muscles.  He  could 
not  sit  still,  or  read,  or  engage  in  a  game  for  long.     He  talked 


STATES   OF   MENTAL  ALTERNATION.  223 

much,  but  could  not  stick  to  one  subject ;  be  was  boastful  in 
a  way  that  was  to  bim  unnatural;  be  spoke  of  bis  private 
affairs,  and  would  indulge  in  very  pointed  questions  and 
remarks,  witbout  mucb  regard  to  your  feelings.  To  a  good 
billiard-player,  "I'll  give  you  fifty  points,  and  bet  a  pair  of 
gloves  I'll  beat  you.  I  don't  want  to  burt  your  feelings,  but 
I  suppose  you  know  your  style  of  play  is  not  very  fine."  To 
a  man  who  had  been  in  trade,  "What  do  you  think  of  my 

stockings,  Mr ?     That  was  in  your  line."     He  was  often 

extremely  amusing,  fluent,  and  witty,  which  he  had  never 
been  when  well.  He  would  rattle  off  Scotch  to  the  pauper 
patients  in  the  grounds,  French  to  the  ladies,  and  Hindustani 
to  himself  in  a  way  he  could  never  do  when  sane.  In  dress 
he  was  untidy,  and  in  habits  dirty.  To  the  ladies,  of  whose 
society  he  was  extremely  fond,  he  was  exaggeratedly  polite, 
with  the  grand  air  of  the  olden  time ;  but  if  they  gave  him 
any  encouragement  he  would  soon  become  too  familiar.  He 
was  always  giving  them  flowers,  which  he  had  stolen,  and 
writing  them  notes,  or  trying  to  kiss  the  maid-servants.  If  he 
had  any  request  to  make  from  a  lady  in  the  drawing-room, 
it  was  no  uncommon  thing  for  him  to  go  down  on  one  knee, 
with  his  hand  to  his  heart,  and  all  this  done  most  gracefully 
and  amusingly,  as  if  half  in  fun  and  much  in  earnest. 

He  smoked  as  much  as  he  could  get,  and  was  always 
grumbling  he  did  not  get  cigars  and  tobacco  enough,  and  beg- 
ging, borrowing,  or  stealing  more.  He  ate  enormously,  but 
not  nicely,  of  everything  that  came  in  his  way.  He  picked 
up  and  appropriated  everything  belonging  to  others  that  he 
had  a  fancy  for,  and  did  this  also  most  gracefully,  as  if  it 
was  the  most  natural  tiling  in  the  world.  He  was  irritable 
when  controlled,  contradicted,  or  refused  requests,  and  he  was 
always  making  innumerable  and  impossible  requests.  He  slept 
badly,  and  would,  if  allowed,  sit  up  all  night,  or  get  up  and 
move  about  by  three  or  four  o'clock  in  the  morning.  He 
was  not  susceptible  to  cold,  sitting  with  all  his  windows  open  in 
winter. 


224  STATES   OF   MENTAL   ALTERNATION. 

He  passed  gradually  out  of  one  stage  into  another .  The 
next  stage  was  a  more  maniacal  one.  He  dressed  more 
grotesquely,  and  always  wanted  to  put  on  three  or  four  coats, 
vests,  or  trousers  on  the  top  of  each  other.  He  would  come 
in  to  a  dance  with  four  vests,  would  go  behind  a  door  or 
another  man,  and  slip  one  and  then  another  off  as  he  got  warm. 
His  habits  and  ways  got  more  dirty  and  disorderly.  His 
irritability  took  violent  forms,  assaulting  his  attendants,  smash- 
ing furniture,  &c.  His  conduct  became  so  uncontrolled  that 
he  could  not  go  to  the  draAving-room  or  to  church.  His  whole 
tastes  as  to  food  were  the  opposite  to  what  they  were  in  health. 
He  liked  porridge,  which  he  could  not  abide  when  well,  and 
if  he  did  not  feel  inclined  to  take  it  he  would  turn  it  out  on 
to  his  newspaper,  put  it  in  his  pocket,  and  eat  it  when  he  felt 
hungry..  He  would  mix  up  soup,  milk,  and  claret,  and  take 
them  together.  Scarcely  anything  was  incongruous  or  disgust- 
ing  to  him.  He  wore  his  hair  very  short,  and  would  singe  it 
or  cut  it  laimself  if  he  could  get  no  one  else  to  do  it.  He 
would,  in  playing  cricket,  strip  himself  almost  naked,  or  put 
on  the  most  ridiculous  things,  a  woman's  hat  or  shawl,  or  a 
cap  turned  outside  in.  He  turned  up  at  morning  prayers  one 
day  in  buckskin  tights,  a  red  vest,  a  blue  cap,  and  black 
swallow-tail.  His  bowels  were  moved  twice  or  three  times  a 
day.  During  all  tliis  time  he  was  losing  or  tending  to  lose 
weight  in  spite  of  all  he  ate.  He  had  his  better  and  worse 
days  all  through,  usually  in  alternation.  He  used  to  paint  and 
draw  pictures  and  portraits. at  this  stage,  producing  the  vilest 
daubs,  spitting  on  the  paper  to  moisten  his  colours,  and  using 
his  hand  and  fingers  to  spread  his  paints.  These  he  would 
carry  in  his  pockets  by  the  dozen,  showing  them  to  any  one 
he  met — and  he  could  pass  no  one  without  speaking,  He  said 
he  had  never  known  he  could  paint  before.  So  with. singing  : 
he  woTild  sing  in  discord,  and  think  he  was  doing  splendidly. 
Yet  with  all  this  there  never  left  him  a  certain  jauntiness  and 
grace  of  manner.  Xo  one,  at  his  worst,  could  have  taken  him 
for  anybody  but  a  high-bred  gentleman. 


STATES    OF   MENTAL   ALTERNATION.  225 

As  this  brain  exaltation  came  on  and  increased  in  every 
successive  attack,  each  little  phase,  each  little  morbid  way, 
such  as  smoking,  eating  certain  kinds  of  food,  cutting  or  singe- 
ing his  hair  and  beard,  painting,  putting  on  one  coat  on  the  top  of 
another,  would  recur  with  the  regularity  of  the  bud,  leaf,  and 
fruit  of  a  tree  each  successive  year. 

The  next  stage  was  the  gradual  subsidence  of  all  these  symp- 
toms of  maniacal  exaltation,  and  a  resumption  of  his  former 
habits  and  ways  and  appearance. 

The  first  stage,  corresponding  to  simple  mania,  lasted  for 
about  a  month ;  the  second,  with  the  symptoms  of  mild  acute 
mania,  about  two  months,  and  his  recovering  stage  about  three 
months,  so  that  the  whole  period  of  exaltation  lasted  six 
months ;  but  he  did  not  stop  at  the  same  stage.  He  at  once 
passed  into  a  condition  of  great  mental  depression.  To  see 
him  in  that,  one  would  scarcely  have  known  him  to  be  the 
same  man.  His  hair  well  grown,  his  whiskers  trim,  his 
features  and  eyes  dull  and  inexpressive,  his  dress  most  scrupu- 
lous and  neat,  his  manner  distant  and  nervous ;  in  speech 
reticent,  and  never  venturing  a  remark ;  in  feeling  depressed, 
fearful,  and  unreliant.  He  thought  he  was  so  wicked  that  he 
should  not  see  any  one.  He  now  disliked  most  of  the  people 
he  had  cultivated  during  his  exaltation,  especially  relying  on 
the  chief  attendant,  who  had  controlled  him  most,  and  whom 
he  had  most  heartily  abused.  His  habits  were  sedentary — he 
could  scarcely  be  got  to  go  for  a  walk ;  his  appetite  was  now 
moderate,  and  his  tastes  very  particular,  not  being  able  to 
bear  the  smell  of  tobacco  nor  to  look  at  porridge  nor  messes  of 
any  kind,  and  most  sensitive  to  dirt  and  bad  smells.  He 
became  very  penurious  about  money.  He  was  always  think- 
ing he  was  doing  wrong  or  giving  offence,  and  did  not  like 
company,  while  he  was  moral  and  very  religious  in  his  feehngs 
and  habits.  His  whole  intellectual  and  affective  life  was  far 
more  unlike  his  exalted  self  than  one  average  man  is  unlike 
another.  He  was  stationary  in  weight  at  first,  but  soon  began 
to  gain.     He  was  very  sensitive  to  cold  and  draughts  and  loud 

p 


226  STATES   OF   MENTAL  ALTERNATION. 

noises,  in  all  of  whicli  he  had  delighted  before.  He  was  full 
of  a  morbid  sorrow  and  regret  for  his  previous  conduct ;  but 
he  was  morbidly  suspicious  at  this  stage,  and  used  to  think 
that  the  things  he  had  given  aAvay  or  destroyed  during  his 
excitement  had  been  stolen.  This  condition  lasted  for  about 
three  months,  gradually  passing  into  one  of  complete  sanity, 
without  depression  or  elevation,  but  with  some  inertness  at  first, 
and  without  much  capacity  for  business.  This  lasted  about 
six  months  and  then  the  signs  of  elevation  again  began.  Alto- 
gether this  circle  of  elevation,  depression,  and  sanity  lasted 
about  fifteen  months.  There  was  no  marked  hne  anywhere, 
though  the  most  distinct  and  sudden  transition  was  between 
the  elevation  and  the  depression. 

The  development  of  the  exaltation  next  time  was  a  slow 
process,  taking  about  two  months  before  it  got  so  bad  that  he 
had  to  come  back  to  the  Asylum.  The  sort  of  things  he  did 
were  going  out  to  ride  at  10  o'clock  p.m.,  never  going  to  bed, 
smoking  all  the  time,  fooKshly  wasting  his  money,  proposing 
to  marry  ladies  and  women  suitable  and  unsuitable,  sometimes 
two  in  a  day,  telling  one,  as  an  inducement  to  accept  him, 
that  if  she  would  marry  him  she  could  put  him  into  an  asylum 
and  enjoy  his  pension !  He  went  into  a  shop  to  buy  a  pair  of 
gloves,  and,  the  shop-girl  taking  his  fancy,  he  went  down  on 
his  knees  to  her,  telling  her  he  had  fallen  in  love  with  her. 
His  nisits  generativus  was  always  exalted  during  the  excite- 
ment, but  seldom  assumed  very  gross  forms.  He  often  said 
that  if  he  could  be  castrated  he  would  be  cured.  The  great 
difficulty  at  this  stage  was  to  get  "facts"  indicating  insanity 
to  put  in  the  medical  certificates  for  his  admission  to  an 
asylum,  for  he  was  very  acute,  and  knew  what  a  doctor's  visit 
meant  quite  well ! 

In  the  second  circle  of  his  disease,  after  coming  to  the 
Asylum,  all  the  symptoms  were  similar  to  the  first,  and  de- 
veloped themselves  in  the  same  order.  The  excitement  was 
more  acutely  maniacal  than  it  ever  was  before  or  has  been 
since.     The  whole  period  of  elevation  lasted  a  year  this  time. 


STATES   OF  MENTAL  ALTERNATION.  227 

the  depression  six  months,  and  the  sanity  six  months,  the 
circle  taking  two  years  to  get  through. 

The  third  circle  had  a  period  of  excitement  of  ten  months, 
of  depression  of  six  months,  and  of  eight  months  of  sanity — 
in  all,  two  years.  The  fourth  circle  had  a  period  of  excite- 
ment of  thirteen  months,  of  depression  of  about  six  months, 
and  of  sanity  of  fourteen  months — in  all,  two  years  and  nine 
months.  He  was  out  of  the  Asylum,  living  at  home,  for  a  year 
and  eight  months  during  part  of  the  depression,  the  whole 
period  of  sanity,  and  the  first  month  of  the  commencement  of 
the  excitement.  He  did  not  enjoy  the  society  of  his  relations 
during  the  depression,  and  they  said  he  would  have  been 
better  to  have  been  in  the  Asylum ;  and  at  the  beginning  of 
the  excitement,  when  they  had  to  remonstrate  with  or  control 
him,  his  affection  for  them  ceased,  and  he  got  on  worse  with 
them  than  in  the  Asylum  with  strangers.  He  said  cruel  and 
unkind  things  to  them. 

In  the  fifth  circle  the  excitement  lasted  two  years,  the  de- 
pression twelve  months,  and  the  sanity  fifteen  months — the 
whole  thus  taking  four  years  and  three  months.  In  the  sixth 
circle  the  period  of  exaltation  lasted  for  three  years,  with  the 
usual  symptoms,  but  none  of  them  were  so  severe  as  they  were 
on  previous  occasions.  It  seemed  as  if,  at  sixty -two,  his  brain 
was  not  capable  of  taking  on  so  acute  an  attack  of  excitement, 
the  nisus  generativus  not  being  so  keen.  During  the  last  period 
of  excitement  he  was  capable  of  being  sooner  tired,  and  took 
rest,  which  he  never  did  before,  and  diurnal  changes  were 
very  marked.  He  had  one  good  and  then  a  bad  day.  But 
the  eroticism,  the  alertness  and  grace  of  movement,  the  klepto- 
maniacal  tendencies,  and  all  the  small  phases  of  his  exaltation 
were  still  present,  there  being  no  trace  of  the  mental  enfeeble- 
ment  of  dementia,  of  bodily  exhaustion,  nor  of  chronic  mania. 
The  period  of  depression  lasted  about  two  years,  and  he  then 
kept  well  for  a  year,  when  at  the  time  the  period  of  exaltation 
should  have  come  on  he  took  a  fearful  attack  of  neuralgia  in 
the  branches  of  the  fifth  nerve,  which  seemed  as  if  it  would 


228  STATES   OF  MENTAL  ALTERNATION. 

kill  liim.  In  a  few  weeks  it  passed  off,  and  lie  has  remained 
sane  for  two  years.  He  has  very  slight  and  irregular  periods 
of  elevation,  not  of  sufficient  intensity  to  require  asylum  treat- 
ment, and  it  seems  as  if  with  advancing  age  and  diminished 
nisus  generativus  he  has  got  over  the  disease,  and  will  remain 
at  home  leading  a  fairly  normal  and  happy  life.  The  damage 
done  to  the  organ  hy  the  previous  attacks  of  exalted  morbid 
energising  has  evidently  been  repaired  in  the  intervals  of 
sanity,  during  which  he  lays  on  flesh  greatly.  The  bromide 
of  potassium  alone,  and  combined  with  cannabis  indica,  did 
not  influence  any  of  the  attacks  of  excitement. 

The  following  is  the  record  of  a  case  of  most  prolonged,  and, 
on  the  ivhole,  one  of  the  most  regularly  alternating  cases  of 
folie  circulaire  in  short  circles  I  have  ever  seen  : — 

D.  B.,  set.  30,  was  admitted  to  the  Eoyal  Edinburgh  Asylum 
in  1847  without  any  history  whatever,  and  she  died  in  1886. 
She  was  a  person  of  education  and  intelligence,  though  sent 
as  a  pauper  patient.  She  laboured  under  all  the  symptoms  of 
acute  mania  at  first,  and  in  a  few  days  it  was  recorded  that 
she  was  "imbecile,"  then  in  a  few  days  more  that  she  was 
quite  well.  From  that  time  till  her  death,  forty  years  after, 
she  had  regularly  recurring  short  attacks  of  acute  mania, 
during  which  she  was  restless,  incoherent,  excited,  destructive 
to  her  clothing,  violent,  and  with  no  memory  or  consciousness 
of  f amihar  things  or  persons,  this  lasting  from  a  week  to  four 
weeks  usually.  This  was  succeeded  by  a  few  days  of  a 
condition  with  all  the  symptoms  of  dementia  Avith  a  little 
depression,  and  she  then  became  practically  sane  for  a  period 
of  from  a  fortnight  to  eight  weeks.  Her  circle  took  from  four 
to  twelve  weeks  to  complete,  enfeeblement  of  mind  taking  the 
place  of  the  more  usual  depression.  We  have  a  wonderfully 
complete  record  of  her  symptoms  all  these  years ;  and  though 
once  or  twice  there  are  such  entries  as  "She  is  now  almost 
continuously  excited,"  as  in  1852  for  a  month  or  so;  or 
"Periods  of  excitement  more  frequent,  of  quiet  shorter,"  as  in 
1853  and  in  1861 ;    "Intervals  of  quiet  longer,"  as  in  1862, 


STATES   OF  MENTAL  ALTERNATION.  229 

yet  the  irregularities  are  no  greater  than  are  common  in 
regard  to  menstruation  in  the  average  woman.  There  can  be 
no  doubt  that  this  was  an  example  of  mental  alternations 
governed  in  their  times  of  occurrence  and  duration  by  the 
menstrual  periodicity.  For  long  she  had  amenorrhoea,  but 
the  return  of  the  catamenia  made  no  difference,  and,  more 
strange,  the  ceasing  of  menstruation  at  the  climacteric  made 
no  difference.  For  four  years  before  her  death  the  regular 
alternations  of  acute  exaltation,  mild  stupor,  and  sanity  were 
not  so  regular  as  before,  and  the  symptoms  of  the  exaltation 
were  scarcely  so  acutely  maniacal  as  at  first.  In  1883  she 
had  an  attack  of  severe  general  convulsions,  succeeded  by  a 
comatose  period,  which  seemed  to  come  on  instead  of  one  of 
the  usual  attacks  of  excitement.  She  recovered  from  the 
excitement,  and  the  usual  alternations  then  went  on  as  before. 
This  was  what  constantly  happens  in  epilepsy,  the  excitement 
being  thus  once  in  forty  years  "larvated."  The  whole  case  is 
otherwise  instructive,  for,  though  it  shows  the  known  tendency 
in  a  brain  for  acute  excitement  to  exhaust  and  destroy  the 
normal  power  of  energising  of  the  convolutions  and  leave  that 
diseased  mentalisation  which  we  call  dementia,  it  also  shows 
this,  that  even  severe  attacks,  when  short,  produce  only  a 
short  enfeeblement,  which  is  recovered  from  soon.  Most 
instructively  of  all,  it  shows  that  over  220  of  such  attacks, 
continued  for  such  an  enormously  long  period  as  forty  years, 
need  not  necessarily  destroy  the  mental  power  of  the  brain  and 
produce  complete  and  permanent  dementia.  The  brain  in 
this  proves  the  recuperative  and  resistive  power  that  it  shows 
in  many  other  ways,  if  the  periods  of  the  exalted  energising,  or 
the  strain,  or  the  poisoning,  or  the  morbidness  is  only  short  in 
time,  and  the  organ  gets  rest  between  one  attack  and  the  next. 
We  all  know  that  periodic  sprees  may  be  continued  with  im- 
punity in  many  people  for  a  hfetime,  and  that  many  men  may 
safely  work  their  brains  at  full  pressure  for  many  years  if  they 
give  them  a  Sunday  rest  and  an  annual  holiday. 

I  had  another  case,  a  lady,  D.  C,  who  was  for  ten  years  in 


230  STATES   OF   MENTAL   ALTERNATION. 

the  Asylum,  who  had  all  that  time  attacks  of  excitement, 
lasting  about  a  fortnight,  alternating  with  periods  of  depression 
for  a  week ;  hut  in  her  case,  as  in  that  of  D.  B.,  the  depression 
immediately  preceded  the  excitement,  and  the  periods  of  sanity 
were  about  three  weeks'  duration.  But,  hke  all  the  rest  of 
the  cases,  the  length  of  the  periods  of  the  different  conditions 
was  not  absolutely  uniform.  In  her  case,  also,  the  regular 
alternations  went  on  up  to  the  age  of  seventy-eight,  when  she 
died,  occurring  only  in  a  mild  form  during  the  last  six  months 
of  her  life,  when  she  had  a  broken  leg,  an  ulcerated  and 
sloughing  ankle,  and  Avas  very  exhausted.  But  her  mind  was 
rather  enfeebled  during  the  quiet  "  sane  "  periods  for  the  last 
ten  years  of  her  life,  and  she  had  sexual  delusions  about  men 
wanting  to  seduce  and  marry  her.  The  exhausting  effects  of 
the  excitement  on  her  brain,  as  in  many  of  the  alternating 
cases,  were  aggravated  by  her  addiction  to  masturbation  during 
the  exalted  periods. 

I  have  now  under  my  care  a  gentleman,  D.  D.,  aged  49, 
who  for  the  past  twenty-six  years  has  been  subject  to  the 
most  regularly  recurring  brain  exaltation  every  four  weeks 
almost  to  a  day.  It  sometimes  passes  off  without  becoming 
acutely  maniacal,  or  even  showing  itself  in  outward  acts;  at 
other  times  it  becomes  so,  and  lasts  for  periods  of  from  one  to 
four  weeks.  It  is  always  preceded  by  an  uncomfortable 
feeling  in  the  head  and  pain  in  the  back,  a  mental  hebetude 
and  shght  depression.  The  nisus  generativus  is  greatly  in- 
creased, and  he  says  that  if  in  that  condition  he  has  full  and 
free  seminal  emission  during  sleep  the  excitement  passes  off; 
if  not,  it  goes  on.  Full  doses  of  the  bromide  and  iodide  of 
potassium  have  the  effect  sometimes,  but  not  always,  of 
stopping  the  excitement,  and  a  very  long  walk  will  at  times 
do  the  same.  "When  the  exaltation  gets  to  a  height  it  is  fol- 
lowed always  by  about  a  week  of  stupid  depression.  It  seems 
as  if  the  depression  in  those  cases  always  meant  a  reaction 
after  morbid  over-action — a  muddy  mental  calm  after  a  storm, 
an  anaesthesia  after  a  hyperaesthesia. 


STATES   OF   MENTAL   ALTERNATION.  231 

In  the  following  case  the  alternations  began  in  old  age  : — 
D.  E.,  set.  74  on  admission,  unmarried,  had  had  several  attacks 
of  excitement  in  the  three  years  previously.  A  sister  is  in- 
sane, and  brother  hemiplegic,  with  periodic  attacks  of  mild 
mental  exaltation,  which  also  came  on  in  advanced  life.  The 
patient  had  been  a  staid  industrious  man,  who  had  been  in 
business  all  his  life,  and  done  his  work  well  till  he  was  over 
seventy,  leading  a  sober  life.  He  has  been  excited  for  three 
months.  It  began  at  first  by  great  mental  exaltation  and 
hilarity  of  manner.  He  was  very  fond  of  the  ladies,  but 
never  erotic.  Especially  he  used  to  laugh  most  immoderately 
at  nothing  in  particular,  putting  down  his  stick  into  the  ground, 
and  bending  forward  and  roaring  with  laughter  from  five  to 
ten  minutes  running.  This  had  exactly  the  efi'ect  of  a  man 
laughing  well  and  continuously  on  the  stage,  at  a  cause  of 
which  you  are  ignorant, — it  was  catching,  and  you  could  not 
help  laughing  too.  This  gradually  passed  into  a  stage  of 
violence,  delusions  of  being  insulted,  shouting,  sleeplessness, 
and  suspicion.  During  the  exalted  period  his  temperature 
was  always  over  99°,  he  ate  enormously,  craved  stimulants, 
his  bowels  were  moved  twice  a  day,  and  he  slept  little.  His 
conduct  was  extremely  ridiculous  for  an  old  man.  His  de- 
lusions were  mere  fleeting  fancies  and  suspicions.  In  four 
months  from  the  beginning  of  his  attack  he  became  depressed, 
and  then  he  never  spoke,  looked  dull  and  heavy,  slept  well, 
and  got  fat,  but  his  bowels  became  very  costive.  All  his 
brightness  and  curiosity  and  much  of  his  intelligence  left  him. 
He  took  no  interest  in  anything.  There  was  much  of  stupor 
in  his  state.  He  felt  little  mental  pain.  After  about  two 
months  he  got  over  his  dulness,  and  became  practically  sane, 
cheerful,  chatty,  and  contented.  After  three  months  of  this 
condition,  or  about  nine  months  from  the  beginning  of  the 
attack,  he  gradually  got  exalted,  passing  through  exactly  the 
same  phases  as  before.  The  excitement  lasted  about  six 
months,  from  March,  to  December,  being  very  mild  for  the 
last  three  months ;  he  then  passed  into  a  two  months'  attack 


232  STATES    OF   MENTAL   ALTERNATION. 

of  stupid  depression  as  before,  and  was  fourteen  months  well, 
his  whole  circle  thus  taking  twenty-two  months  to  complete. 
He  next  got  exalted  in  December,  and  was  acutely  excited  for 
about  three  weeks  only,  and  then  had  an  attack  of  extreme 
stupor,  depression,  weakness,  and  prostration  for  three  months. 
He  then  became  sane,  but  almost  at  once  passed  into  another 
attack  of  excitement.  The  whole  duration  of  this  circle  was 
only  four  months.  The  excitement  that  followed  was  more 
acute  than  he  had  ever  had  before ;  it  lasted  five  months,  and 
was  followed  at  once  by  great  depression  lasting  for  six 
months.  He  was  then  sane  for  three  months,  this  circle 
taking  fourteen  months  to  complete.  This  time  he  became 
exalted  in  May.  This  circle  took  twenty-one  months  to  com- 
plete. In  December  he  became  exalted  again,  his  irritability 
being  very  great  this  time,  and  his  hilarious  happiness  less 
marked.  He  remained  so  for  nine  months,  and  then  became 
depressed  rather  suddenly,  passing  into  a  condition  of  nearly 
complete  stupor,  and  leading  an  almost  vegetative  life.  He 
remained  so  for  almost  five  weeks,  and  then,  without  the  usual 
intermediate  period  of  sanity,  he  suddenly  one  night  became 
delirious,  with  hallucinations  of  sight,  but  this  only  lasted  for 
one  day.  He  was  after  that  four  days  depressed,  and  again 
got  exalted,  with  more  decided  delusions  than  he  had  ever 
had  before.  This  lasted  less  than  two  months,  and  he  then 
passed  into  an  attack  of  stupor  again.  By  this  time  he  was 
eighty-two  years  of  age,  and  he  had  an  epithelioma  of  one  of 
his  great  toes,  with  irritation  and  suppuration,  which  acted  as 
a  drain  and  irritant.  The  toe  was  amputated  by  Mr  Bell,  and 
he  made  a  good  recovery,  and  he  gained  in  flesh  and  strength, 
but  remained  in  the  condition  of  depressed  partial  stupor  for 
three  years,  lying  in  bed  mostly.  He  would  answer  questions 
when  spoken  to,  but  never  ventured  a  remark  or  took  any 
notice  of  anything.  He  remained  in  this  state  of  complete 
senility  and  mental  torpor  till  his  death  at  eighty-five.  When 
carefully  observed  his  torpor  was  seen  to  be  more  intense  at 
times  than  others,  and  he  signed  his  name  diiferently  at  dif- 


STATES   OF   MENTAL  ALTERNATION.  233 

ferent  times,  showing  a  certain  kind  of  passive  periodicity  till 
his  death. 

In  this  case,  as  in  most  of  the  others  that  I  have  seen  with 
prolonged  alternations,  they  were  irregular;  but  in  him  the 
periods  of  excitement  always  began  in  cold  weather,  from 
October  to  May.  The  most  striking  circumstance  about  the 
case  is  its  commencement  at  seventy-four,  after  the  intensity 
of  the  sexual  period  of  life  was  past.  It  is  only  the  third  case 
of  that  kind  I  have  known.  The  excitement  coming  on  in 
spurts  for  a  few  days  at  the  last  attack,  as  if  the  senile  brain 
had  no  longer  vigour  enough  to  keep  up  a  prolonged  exalta- 
tion, would  seem  to  be  one  of  the  endings  of  alternating 
insanity. 

In  the  following  case  of  D.  F.,  the  attacks  of  excitement  and 
those  of  depression  ceased  at  the  age  of  sixty-five,  after  alter- 
nations of  the  two  had  lasted  for  twenty  years.  He  was  an 
artist,  but  could  only  paint  at  the  beginning  of  the  period  of 
exaltation  and  at  the  end  of  it.  He  never  could  finish  a 
picture,  and  if  he  attempted  to  do  so  he  got  worse  mentally. 
So  long  as  painting  was  spontaneous  or  pleasurable  he  did  it, 
and  it  did  him  no  harm.  If  he  could  not  catch  a  likeness,  or 
tried  to  elaborate  or  paint  in  details,  or  had  nothing  but 
drudgery  to  do  he  got  worse.  In  his  case  there  was  very 
marked  exaltation  of  the  memory,  and  his  fancies  always  took 
the  pleasant  form  of  a  loss  of  his  own  personal  identity  and 
the  assumption  of  that  of  the  author  whose  works  he  was 
reading  or  repeating.  As  he  got  better  he  would  tell  me  that 
he  was  very  happy  indeed  as  he  lay  awake  at  nights,  for  he 
would  fancy  he  was  Shakespeare,  Burns,  or  King  David, 
as  he  repeated  aloud  their  works.  He  could  vividly  recall 
the  events  of  his  boyhood,  and  repeat  long  conversations  he 
had  held  with  his  friends  then.  His  eyesight  and  hearing 
became  very  acute,  so  that  he  could  read  small  print,  and 
paint  without  spectacles,  and  hear  whispers;  while,  as  the 
exaltation  wore  off,  he  had  to  use  stronger  and  stronger 
spectacles,  and  was  very  deaf.     When  depressed,  all  his  bodily 


234  STATES   OF   MENTAL   ALTERNATION. 

functions,  appetites,  and  propensities  were  torpid  and  sluggish. 
There  was  a  difference  of  2 "2°  between  his  average  temperature 
during  exaltation  and  depression.  There  is  in  the  case-hooks 
of  the  Carhsle  Asylum  a  careful  record  of  his  condition  from 
1862,  till  his  death  in  1876.  Mt.  54,  1862,  January,  exalted  ; 
July,  pretty  well :  1863,  July,  quite  well ;  October,  depressed  : 
1864,  February,  exalted;  July,  depressed;  October,  quite 
well  :  1865,  April,  depressed ;  August,  exalted  :  1866, 
January,  quite  well,  and  remained  so  till  1867,  when  in  July 
he  got  depressed,  and  in  December  his  alternations  were 
diurnal,  he  being  one  day  depressed  and  the  next  very  excited, 
this  lasting  for  a  month  or  two  :  1868,  July,  became 
depressed ;  October,  quite  well :  1869,  April,  depressed,  and 
was  so  till  October,  when,  instead  of  the  usual  and  expected 
exaltation,  he  got  quite  well,  and  kept  so  for  over  three  years, 
till  January  1873,  when  he  had  a  short  attack  of  mild 
exaltation,  lasting  for  three  months.  He  then  kept  well  till 
January  1874,  when  he  had  a  few  occasional  days  of  slight 
excitement,  at  irregular  intervals,  and  then  got  quite  calm 
and  rational,  though  not  energetic, — in  fact,  he  got  into  a 
typical  and  normal  senile  condition  of  mind  and  body,  his 
brain  remaining  in  this  quiet  haven  of  rest  after  its  twenty 
years  of  violent  alternations  of  storm  and  sluggishness,  till  he 
died  of  bronchitis  in  the  end  of  1876,  at  sixty-eight.  In  this 
case  it  will  be  observed  that  there  was  a  distinct  tendency 
for  the  periods  of  exaltation  to  occur  in  the  early  part  of  the 
year,  in  January  and  February,  and  the  periods  of  depression 
to  come  on  towards  the  end  of  the  year,  from  October  to 
December.  The  periods  of  depression  did  not  follow,  but 
precede,  the  exaltation  in  this  case,  contrary  to  the  usual 
experience.  One  should  perhaps  say  that  the  excitement 
followed  and  seemed  to  be  a  reaction  from  the  depression. 

The  following  dates  of  the  admission  and  discharge  of  D.  I. 
show  the  length  of  the  attacks  in  his  case,  for  he  is  sent  to  the 
Asylum  whenever  he  gets  exalted,  and  is  sent  home  when  the 
excitement  passes  off.     He  is  then  not  very  painfully  depressed, 


STATES   OF   MENTAL  ALTERNATION.  235 

quiet,  penurious,  and  unsocial,  sluggish  for  two  or  three 
months,  and  then  gets  quite  sane  and  does  his  business  very 
well.  His  exaltation  is  of  the  typical  kind  —  talkative, 
energetic,  passionate,  quarrelsome,  abusive,  restless,  sleepless, 
but  never  incoherent,  and  very  fond  of  spending  his  money 
lavishly.  He  once  got  off  to  London  about  the  beginning  of 
an  attack  with  £1000  in  his  pocket,  with  the  deliberate 
intention  to  spend  it  in  a  month  and  enjoy  himself,  as  he  said 
he  had  "led  too  quiet  a  life  at  home,"  and  he  pretty  nearly 
got  through  it.  I  have  reason  to  believe  that  he  once  made  a 
large  sum  of  money  during  one  of  his  exalted  brilliant  periods, 
just  as  he  was  passing  into  the  elevated  part  of  a  morbid 
mental  circle.  Hopefulness,  superabundant  energy,  mental 
subtilty,  argumentativeness,  wildness,  a  strong  leaning  towards 
the  other  sex  but  not  an  offensive  eroticism,  characterise  this 
period.  The  dates  show  the  irregularity  of  the  seasons  at 
which  the  attacks  came  on,  and  of  their  duration.  He  was 
forty -five  when  first  admitted,  and  he  had  had  a  few  attacks 
previously.  Admitted  October  1866,  discharged  January 
1867;  admitted  April  1870,  discharged  May  1870;  admitted 
August  1871,  discharged  September  1871 ;  admitted  December 
1872,  discharged  February  1873;  admitted  February  1875, 
discharged  May  1875 ;  admitted  August  1877,  discharged 
September  1877;  admitted  November  1880,  discharged 
January  1881 ;  admitted  December  1881,  discharged  March 
1882. 

Duration  of  Periods. — An  examination  of  the  exact  periods 
during  which  the  exaltation,  depression,  and  sanity  persist, 
their  relation  to  each  other  during  different  recurrences,  and 
the  sizes  and  regularity  of  the  successive  circles  in  each  case, 
shows  this  far  more  than  I  had  supposed  previously  to  more 
exact  investigation,  viz.,  that  the  periods  are  not  often  always 
the  same  in  the  same  patient  at  different  times,  and  that,  in 
fact,  very  few  of  them  are  perfectly  regular  and  typical  in 
their  symptoms.  I  only  find  about  one  or  two  out  of  forty 
cases  of  folie  circulaire  that  were  absolutely  regular.     In  others 


236  STATES   OF   MENTAL  ALTEKXATIOX. 

the  periods  of  excitement  were  often  twice  as  long  in  one  circle 
as  in  another,  and  the  periods  of  depression  and  sanity  varied 
also.  The  age,  state  of  the  general  health,  conditions  of  hie, 
critical  periods,  diet,  medicines  such  as  a  combination  of  the 
bromides  and  Indian  hemp  and  sulphonal,  have  all  the  power 
of  modifying  the  length  and  the  intensity  of  the  periods  of 
exaltation.  We  shall  see  how  important  those  facts  are,  taken 
in  conjunction  with  the  views  as  to  the  essential  nature  of  the 
alternations  which  I  am  to  speak  of. 

While  a  typical  case  of  alternating  insanity  is  not  hopeful, 
yet,  in  prognosis,  we  must  not  conclude  that  a  case  is  incurable 
merely  because  there  are  recurrences  and  alternations  for  a  few 
months  or  for  a  year,  or  even  for  two  or  three  years. 

Differences,  Mental  and  Bodily,  between  Periods  of  Exaltation 
and  Depression. — It  is  very  interesting  and  most  important  to 
study  minutely  the  exact  psychological  differences  in  the  same 
brain  when  morbidly  elevated,  and  depressed,  and  sane ;  and 
it  is  almost  equally  important  to  compare  the  differences  in  the 
bodily  symptoms  of  the  two  former  conditions.  The  cases  I 
have  recorded  show  many  of  these  differences  and  symptoms. 
In  the  elevated  stage,  either  at  the  beginning  or  all  through 
it,  there  is  an  actual  exaltation  of  many  of  the  mental  faculties, 
notably  of  memory,  of  general  acuteness  and  abihty  to  reason 
in  a  way.  The  mentahsation  is  almost  unceasing  in  some  form, 
but  the  common  sense  is  gone ;  the  power  of  self-control  and 
of  carrying  out  definite  mental  work  is  gone ;  the  power  of 
attention,  while  it  may  be  very  acute  in  some  ways,  is  not 
under  the  control  of  volition ;  there  is  often  great  subtilty  of 
reasoning  and  a  marvellous  capacity  to  explain  away  eccen- 
tricities of  conduct ;  there  is  intolerance  of  contradiction ; 
there  is  a  cliildishness  of  mental  condition  in  some  respects, 
with  a  foolish  credulity ;  affectively  the  patient  is  morbid, 
though  he  feels  happy,  yet  his  emotions  are  always  shallow, 
and  directed  in  fits  and  starts  chiefly  towards  objects  and 
persons  that  are  present,  being  always  weakened  towards  or 
withdrawn    from   their  natural   objects — Avife,  children,  &c. 


STATES   OF  MENTAL  ALTERNATION.  237 

There  is  a  most  remarkable  change  in  the  appetites,  which 
are  usually  quite  perverted  from  what  was  natural  to  the 
patient.  Different  kinds  of  food,  drink,  and  stimulants  are 
sought  for  and  enjoyed.  The  general  feeling  of  hien-etre  is 
exaggerated.  The  courage  is  exaggerated,  and  there  is  little 
caution  left.  There  is  an  intense  desire  to  attract  attention. 
The  reasonable  conventionalities  are  not  observed.  There  is 
always  extravagant  and  morbid  generosity.  The  social  instincts 
are  enlarged,  lowered  in  tone,  and  they  become  somewhat  pro- 
miscuous, a  man  nearly  always  seeking  the  company  of  his 
inferiors  in  station. 

In  the  stage  of  depression  the  natural  affections  towards 
children  usually  return  or  flow  into  their  natural  channels  with 
much  force,  but  the  subjective  feeling  of  the  patient  is  one  of 
misery  and  ill-being ;  he  has  no  courage,  no  power  to  resolve, 
no  general  activity  of  mind.  In  all  the  typical  cases  there  is 
a  sort  of  torpor  and  inactivity  of  mind,  there  is  niggardhness 
in  money  spending,  in  wearing  clothes,  &c.  There  is  often  a 
feeling  of  profound  disgust  and  regret  at  the  extravagant  and 
foolish  acts  of  the  excited  period. 

The  changes  in  the  bodily  symptoms  are  very  marked.  The 
patient,  when  exalted,  loses  weight ;  when  depressed  he  gains 
weight ;  the  difference  in  weight  between  the  two  periods  being 
often  two  stones.  When  excited  he  takes  much  exercise,  is 
restless,  and  never  tires.  When  depressed  he  is  sluggish,  and 
dislikes  exercise,  and  is  soon  tired.  In  the  former  stage  his 
temperature  is  above  the  normal,  especially  in  the  evening ;  in 
the  latter  below  it,  the  average  difference  being  1'1°,  and  in 
some  individual  cases  3'6°.  In  the  former  he  can  bear  cold 
well,  and  likes  it;  in  the  latter  he  cannot  bear  cold,  and 
dislikes  it  much.  In  the  former  his  bowels  are  very  regular, 
and  often  moved  more  than  once  a  day ;  in  the  latter  they  are 
costive.  In  the  former  his  face  is  mobile  and  expressive,  and 
his  eyes  glistening;  in  the  latter  they  are  heavy.  In  the 
former  he  is  always  hungry,  and  his  capacity  for  eating  and 
digesting  everything  almost  unlimited ;  in  the  latter  he  may 


238  STATES   OF   MENTAL  ALTERNATION. 

eat  "well,  but  is  very  particular  as  to  food.  In  tlie  former  he 
craves  stimulants  and  tobacco ;  in  the  latter  he  often  loathes 
them.  In  the  former  he  is  not  sensitive  to  disagreeable  odours, 
sounds,  and  sights ;  in  the  latter  he  is  usually  hyper-sensitive. 
In  the  former  the  skin  is  moist  and  perspiring ;  in  the  latter 
it  is  usually  dry  and  often  hard,  and  skin  diseases,  such  as 
psoriasis,  not  unf requently  appear.  While  exalted  the  patient's 
pulse  is  usually  full  and  hard;  while  depressed,  small  and 
compressible.  In  the  former  the  sexual  appetites  and  capacity 
are  always  increased ;  in  the  latter  they  are  often  paralysed. 
(One  gentleman  told  me  that  for  two  years  he  had  no  sexual 
feeling  or  power.)  The  sight  and  hearing  are  often  much 
more  acute  in  the  former  than  in  the  latter.  In  the  former 
state  the  patient  sleeps  little  and  hghtly ;  in  the  latter  long 
and  soundly. 

Many  ordinary  nervous  symptoms  folloAv  the  periodicity 
and  alternation  of  the  mental,  I  had  one  woman  whose  circle 
took  about  six  weeks  to  complete,  and  whose  period  of  elevation 
was  always  preceded  and  ushered  in  by  severe  cephalalgia  and 
then  by  vomiting.  I  have  had  several  women  in  whom  the 
depressed  period  was  preceded  by  neuralgia.  Several  of  my 
patients  can  tell  beforehand  when  they  are  going  to  get  excited, 
by  their  bodily  feehngs. 

Katatonia. — One  form  of  alternation  has  been  called 
katatonia  by  Kahlbaum.  It  is  an  alternating  insanity  in  which 
there  are  either  epileptiform  symptoms  or  those  resembling 
catalepsy,  hallucinations  of  sight  and  hearing,  unconsciousness, 
with  trophic  symptoms,  such  as  oedema  and  weak  pulse,  these 
preceding  or  accompanying  the  melancholic  stage.  It  is  simply 
a  variety  of  the  disease  in  which  the  functions  of  the  motor 
and  tropliic  centres  are  specially  involved. 

Relationship  to  Physiological  Periodicities. — I  have  for  a  long 
time  been  impressed  with  the  relationship  of  the  mental  and 
bodily  alternations  and  periodicity  in  insanity  to  the  great 
physiological  alternations  and  periodicities,  and  I  have  gradually 
been  led   to  the  conclusion   that   they  are    the  same   in  all 


STATES   OF  MENTAL  ALTERNATION.  239 

essential  respects,  and  only  differ  in  degrees  of  intensity  or 
duration.  By  far  the  majority  of  tlie  cases  in  women  follow 
the  law  of  the  menstrual  and  sexual  periodicity ;  the  majority 
of  the  cases  in  men  follow  the  law  of  the  more  irregular 
periodicity  of  the  nisus  generativus  in  that  sex.  Many  of  the 
cases  in  both  sexes  follow  the  seasonal  periodicity,  which 
perhaps  in  man  is  merely  a  reversion  to  the  seasonal  generative 
activities  of  the  majority  of  the  lower  animals. 

Relapses  in  Ordinary  Insanity. — A  careful  clinical  study  of 
mental  diseases  reveals  the  fact  that  there  exists  in  the 
majority  of  all  the  acute  cases,  at  some  time  or  other,  in  some 
form  or  degree,  in  the  course  of  the  disease,  a  tendency 
to  alternation,  periodicity  of  symptoms,  remissions,  or  recurring 
relapses.  I  have  taken  the  338  cases  of  mental  disease 
admitted  to  Morningside  Asylum  in  1881, — 181  of  them 
being  cases  of  mania,  and  129  of  melancholia,  the  rest  being 
general  paralysis,  dementia,  &c., — and  I  find  that  in  81  of  the 
female  cases,  or  46  per  cent,  in  that  sex,  and  in  67  of  the 
men,  or  40  per  cent,  of  that  sex,  there  was  relapse,  alternation 
or  periodicity  of  symptoms  in  the  course  of  their  attacks. 
Many  of  the  338  admissions  were  chronic  on  admission,  so 
that  of  the  recent  cases  the  decided  majority  showed  those 
symptoms.  50  of  the  129  cases  of  melancholia,  or  39  per 
cent.,  and  98  of  the  181  cases  of  mania,  or  54  per  cent.,  were 
alternating  or  relapsing,  or  showed  diurnal,  or  monthly,  or 
seasonal,  or  sexual  periodicity.  It  may  therefore  be  concluded 
that  insanity  in  the  female  sex  has  more  of  this  character 
than  in  men,  and  that  the  cases  of  mania  have  it  to  a  greater 
degree  than  those  of  melanchoha.  In  some  patients  it  was 
a  morning  aggravation  and  evening  improvement,  those  being 
usually  cases  of  melanchoha;  in  a  few  it  was  an  evening 
aggravation,  those  being,  contradictorily,  also  cases  of  melan- 
choha. Yery  many  cases  of  mania  were  more  exalted  one  day 
and  less  so  the  next ;  many  sleeping  and  waking  on  alternate 
nights,  these  being  usually  cases  of  mania.  The  attendants 
are  very  strong  on  this  point  of  the  "good"  and  "bad"  days 


240  STATES  OF  MENTAL  ALTEKNATION, 

of  these  patients,  and  calculate  much,  on  them.  Many  of  the 
cases  had  remissions  and  relapses  of  a  few  days  regularly  for 
a  time.  Some  had  monthly  or  menstrual  aggravations.  In 
some  cases  these  periodic  remissions  occurred  most  at  the 
beginning  of  the  attack,  but  in  far  more  cases  towards  the  end 
of  it,  and  during  the  convalescence  of  the  patient.  I  had 
a  lady  lately  under  my  care,  convalescing  from  acute  mania — 
D.  K.,  a  strong,  healthy  woman  of  38,  who  had  recently 
recovered  from  a  bad  attack  of  rheumatic  arthritis.  First 
attack,  duration  ten  days,  with  a  heredity  to  insanity.  She 
remained  in  a  state  of  acute  excitement  for  about  a  week 
after  admission,  getting,  however,  at  intervals  sufficient  sleep 
and  sufficient  nourishment.  An  abatement  of  the  disease 
then  set  in,  and  from  that  period  there  was  a  slow  but  steady 
improvement  until  seven  weeks  after  admission,  when  she  was 
discharged,  having  made  an  excellent  recovery.  The  most 
striking  feature  in  the  case,  during  the  latter  weeks  of  its 
course,  was  the  distinct  daily  morning  exacerbation  and 
evening  remission.  Each  morning  showed  a  distinct  improve- 
ment on  the  previous  morning,  but  a  distinct  relapse  as 
compared  with  the  previous  evening,  while  each  evening  she 
appeared  to  be  further  on  the  road  to  recovery  than  she  was 
the  evening  before.  In  the  morning  she  would  be  full  of 
doubts,  suspicions,  and  querulousness,  while  the  evening 
would  find  her  sensible,  cheerful,  and  grateful.  The  change 
would  come  on  in  a  few  minutes  without  external  cause. 
Even  when  convalescence  was  well  advanced,  the  morning 
was  for  her  a  period  of  distress  and  distrust,  but  with  the 
evening  came  quiet,  rest,  and  a  thankful  heart.  I  have  now 
tmder  my  care  a  gentleman — J.  M. — who  for  over  two  years 
has  suffered  from  melanchoha  with  regular  diurnal  changes. 
One  day  he  is  fairly  cheerful,  plays  games,  reads  the  papers, 
and  expresses  no  delusions.  J^ext  day  he  is  very  depressed, 
says  he  is  going  to  die,  that  I  shall  certainly  not  see  him 
again,  he  is  suicidal,  cannot  fix  his  attention  on  anything, 
makes  grimaces,  and  is  restless.     The  change  from  the  bad  to 


STATES   OF  MENTAL  ALTERNATION.  241 

the  good  or  from  the  good  to  the  bad  state  takes  place  iii  the 
evening. 

Such  a  case  is  merely  a  type  of  what  is  very  common  in  all 
forms  of  mental  disease,  especially  during  convalescence.  A 
medicail  man  in  attendance  should  always  prepare  the  minds 
of  relatives  for  this  tendency  to  relapse  and  alternate. 
I^othing.  is  more  discouraging  to  both  the  doctor  and  the 
relations  when  it  persists  for  a  long  time ;  but  it  is  our  duty 
to  keep  up  their  hopes  and  ours,  and  to  think  of  and  refer  to 
examples  where  the  tendency  has  been  quite  got  over,  even 
after  a  long  time.  I  once  had  a  young  man  of  twenty  who 
took  regular  relapses  for  five  years,  and  after  that  made  an 
admirable  recovery,  and  to  my  own  knowledge  has  done  his 
work  well  and  has  kept  well  for  ten  years.  Taking  the 
chronic  incurable  cases  now  in  the  Asylum,  I  find  that  about 
40  per  cent,  of  them  are  subject  to  aggravations  of  their 
mental  condition  at  times. 

Causation. — I  find  that  the  younger  the  patient  the  greater 
is  the  tendency  to  periodic  alternation,  remission,  and  relapse. 
The  phenomenon  finds  its  acme  in  the  cases  of  pubescent  and 
adolescent  insanity. 

I  have  had  cases  in  which  the  following  exciting  causes 
Avere  assigned  for  the  first  outbreak  of  excitement  or  depression 
in  folie  circulaire,  viz.,  mental  shock  and  strain,  sunstroke, 
brain  syphilis,  and  traumatic  injury  to  head. 

I  also  find  that  the  stronger  the  heredity  the  greater  the 
tendency  to  periodic  relapses  and  alternations.  I  have  never 
met  with  a  single  case  that  could  be  called  typical  folie 
circulaire  where  •  there  was  not  hereditary  predisposition  to 
insanity.  It  seems  as  if  there  were  certain  brains  so  con- 
stituted as  to  be  incapable  of  energising  except  irregularly, 
swinging  between  elevation  and  depression.  The  above  facts 
and  statistics  refer  to  ordinary  remissions ;  but,  on  the  other 
hand,  the  infrequency  of  cases  with  such  regular  and  con- 
tinuous alternations  as  to  be  properly  called  folie  circulaire 
may  be  seen  from  the  fact  that,  out  of  800  patients  in  the 

Q 


242  STATES  OF  MENTAL  ALTERNATION. 

Asylum  at  Morningside  now,  there  are  only  16  of  tMs  kind, 
or  2  per  cent.,  and  of  the  last  3000  new  admissions,  comprising 
about  2000  fresh  cases  of  insanity,  less  than  10  have  as  yet 
turned  out  of  this  character.  Eut  of  course  I  do  not  iuclude 
the  cases  with  rherely  long  remissions,  or  the  cases'  with  re- 
lapses for  the  first  year  or  two,  or  the  demented  cases  with 
occasional  spurts  of  '  excitement,  or  the  women  with  a  few 
irritable  days  at  menstruation,  though  many  of  these  are  of 
the  same  essential  nature  as  the  most  typical  cases  of  folie 
circulaire,  following  the  same  laws  of  physiological  periodicity 
in  an  irregular  way. 

Statistics. — I  have  had  under  my  care  altogether  over  forty 
cases  of  typical  folie  circulaire.  Of  these  about  one-half ' 
followed  a  more  or  less  regular  monthly  periodicity.  About 
one-third  obeyed  the  law  of  seasonal  periodicity,  all  in  an 
irregular  way ;  and  the  remaining  sixth  I  could  bring  under 
no  known  law,  on  account  of  their  irregularity.  I  had  lately 
an  extraordinary  case,  a  lady,  who  was  for  a  year  deeply 
depressed,  then  for  several  years  quite  well,  then  for  seven 
years  more  deeply  depressed,  then  for  three  months  passed  for 
sane,  but  was  really  mildly  exalted,  then  was  depressed  for  a 
year,  and  was  exalted,  with  all  the  typical  symptoms  of 
typical  folie  circulaire,  for  two  years,'  and  then,^  soon  after 
passing  into  the  depressed  condition,  dying  of  cancer  of  the 
mamma. 

Commencement  of  the  Alternating  Tendency. — Though  there 
are  a  few  cases  that  begin  Avith  attacks  of  melanchoha,  yet  iu 
my  experience  at  least  90  per  cent,  began  their  actual  insanity 
with  attacks  of  maniacal  exaltation.  The  ages  of  the  patients 
on  the  first  breaking  out  of  the  disease  were  all  the  way 
from  fifteen  to  seventy-four ;  but  every  one,  except  the  one 
D.  C.  (p.  229),  began  within  the  actively  sexual  and  pro- 
creative  period  of  life.  I  find  no  record  of  a  woman's  case 
beginning  long  after  the  climacteric  period. 

Termination  of  Typical  Folie  Circulaire. — As  this  cannot 
be  determined  till  after  the  patients  have  died,  it  is  impossible 


I 


STATES   OF   MENTAL   ALTEENATION.  243 

for  me  to  give  accurate  figures  ;  but,  of  forty  cases,  five  ceased 
to  be  subject  to  alternation  in  old  age  after  sixty ;  one  of 
these  was  above  eighty,  two  being  women.  The  men  were 
all  left  in  a  condition  of  mind  and  brain  that  might  be 
legally  reckoned  sanity,  though  in  all  cases  there  was  some 
mental  enfeeblement  or  a  tendency  to  be  easily  upset,  with 
lethargy,  want  of  spontaneity  and  of  volitional  power.  One 
case  terminated  in  complete  dementia.  Two  ran  on  into 
chronic  mania.  Two  died  of  exhaustion  during  a  maniacal 
period.  Five  things  may  be  said  about  the  prognosis  — 1,  its 
utter  uncertainty ;  2,  recovery  cannot  be  looked  for  at  the 
climacteric  period  in  many  cases ;  3,  about  20  per  cent,  may 
be  expected  to  settle  down  into  a  sort  of  quiet,  comfortable, 
slightly  enfeebled  condition  in  the  senile  period  of  Uf e ;  4, 
in  my  experience  very  few  indeed  become  completely  de- 
mented; 5,  the  tendency  to  death  is  very  slight. 

General  Conclusions. — Looking  at  all  those  facts  and  con- 
siderations, therefore,  I  come  to  these  conclusions :  That 
periodicity,  or  a  tendency  to  alternations  of  elevation  and  de- 
pression, is  a  very  common  characteristic  of  mental  diseases ; 
that  it  is  much  more  marked  where  they  are  very  hereditary 
than  in  any  other  cases ;  that  it  is  more  common  in  youth, 
puberty,'  and  adolescence  than  at  other  periods ;  that  it  is  in 
its  essential  nature  merely  the  exaggerated  or  perverted  physio- 
logical diurnal,  menstrual,  sexual,  or  seasonal  periodicities  of 
the  healthy  brain ;  that  the  cases  that  have  been  called  folie 
circulaire,  katatonia,  &c.,  are  merely  typical  or  exaggerated  or 
more  continuous  examples  of  that  universal  tendency  to 
which  I  have  referred.  Another  remarkable  fact  about  the 
typical  form  of  alternating  insanity  is,  that  by  far  the 
greater  number  of  patients  who  suffered  from  it  were  persons 
of  education,  and  far  more  than  a  due  proportion  of  them  were 
members  of-  old  famihes.  I  never  met  with  a  fine  case  in  a 
person  whose  own  brain  and  whose  ancestors'  brains  had  been 
uneducated.  It  seems  to  me  that  the  tendency  to  alternation 
of   mental  condition,   to  energise  at  one  time  with  morbid 


244  STATES   OF  MENTAL  ALTEENATION. 

hurry  and  then  with  morbid  slackness,  is  one  of  the  forms  of 
brain  instability  which  specially  results  from  too  much  "pure- 
ness  of  blood,"  or  from  the  heredity  of  many  generations  of 
gentlefolks,  all  of  Avhose  brains  had  been  more  or  less  edu- 
cated. Probably  it  is  one  of  the  modes  by  which  nature  brings 
that  kind  of  stock  to  an  end  that  has  become  bad  by  over- 
brain  cultivation  for  many  generations. 

Eeal  work  can  sometimes  be  done  during  the  sane  periods. 
D.  D.  has  done  some  literary  work,  in  the  intervals  of  his 
attacks,  for  the  twenty-six  years  he  has  been  ill. 

I  have  no  doubt  that  it  was  the  sexual  and  menstrual 
periodicity  of  mental  diseases,  seen  in  so  many  cases,  that 
formerly  originated  the  absurd  idea  that  insanity  was  influenced 
and  caused  by  the  moon's  changes,  and  which  gave  it  the  name 
of  "lunacy." 

Treatmeni. — The  great  point  in  treatment  is  to  prevent  the 
brain  getting  into  the  vicious  circle  of  continuous  alternation 
by  endeavouring  really  to  complete  the  cure  in  all  cases  of 
mania — especially  in  all  cases  of  adolescent  mania — and  to 
enforce  prolonged  quiet  and  brain-rest  after  attacks  in  persons 
who  have  shown  a  tendency  towards  recurrence  and  relapse. 
In  them  particularly  the  whole  organism  should  be  kept  up 
to  physiological  perfection.  I  beheve  that  a  non-stimulating 
farinaceous  vegetable  diet  and  no  alcohol  is  the  best  for  them, 
with  an  outdoor  life  and  plenty  of  muscular  exercise.  A 
regular  mode  of  life,  too,  without  excitement,  is  best.  One 
thing  which  I  have  heard  recommended,  and  which  is  very 
liable  to  be  resorted  to  in  the  beginning  of  the  exalted  stage, 
when  the  patient  is  very  erotic,  is  marriage,  but  I  have  never 
seen  any  good  come  of  it  either  by  cure  or  prophylaxis.  I 
once,  with  Dr  Heron  "Watson,  had  to  stop  the  banns  in  the 
case  of  a  lady  who  had  been  seduced  in  the  beginning  of  the 
exalted  erotic  stage  of  this  disease,  and  was  going  to  be  married 
for  her  money  by  a  scoundrel  who  had  taken  advantage  of  her 
mental  condition.  I  mentioned  in  the  case  of  D.  A.  that  he 
usually  proposed  to  many  ladies  at  the  beginning  of  his  exalted 


STATES   OF   MENTAL  ALTERNATION.  245 

attacks.  There  are  only  two  medicines  that  I  know  which 
have  any  power  of  stopping  or  cutting  short  attacks,  and  of 
sometimes  averting  them  for  a  long  time  and  of  even  curing 
them,  and  these  are  the  bromides,  especially  combined  at  the 
more  acute  stages  with  Indian  hemp,  and  sulphonal.  The 
following  cases  illustrate  this  action  : — 

D.  F.,  set.  23.  This  young  woman  has  had  six  attacks  of 
exaltation  in  four  years.  She  had  been  insane  for  four  weeks 
previous  to  admission.  All  the  attacks  had  begun  during 
menstruation,  and  while  maniacal  she  was  always  very  erotic, 
especially  at  the  beginning  of  the  excitement.  She  was  violent, 
incoherent,  noisy,  dirty  in  her  habits,  and  sleepless  before 
admission  and  for  about  three  months  afterwards.  She  then 
got  well,  but  in  six  months  had  another  similar  attack  of 
mania,  lasting  for  two  months.  She  lost  28  lbs.  in  weight 
during  this  attack,  and  her  temperature  was  always  1*5°  above 
its  normal  rate  during  the  excitement.  She  remained  free 
from  excitement  for  nine  months,  and  then  had  another 
similar  attack.  After  four  months  of  sanity  she  one  night 
suddenly  got  up,  smashed  the  windows  of  her  dormitory, 
saying  that  the  devil  was  looking  in,  and  became  violently 
excited,  her  temperature  that  day  being  100'8°,  pulse  108  and 
strong.  She  was  ordered  drachm  doses  of  the  bromide  of 
potassium  every  three  hours,  with  a  drachm  of  ammoniated 
tincture  of  valerian  with  each  dose.  She  was  put  into  a  dark 
room  at  her  own  suggestion.  On  the  following  day  her 
temperature  was  99*6°,  and  her  pulse  108.  She  was  still 
much  excited,  but  iiot  so  much  so  as  on  the  day  before.  On 
the  second  day  her  temperature  was  99*3°,  and  her  pulse  130 
and  weak,  the  excitement  being  much  allayed.  The  medicine 
was  after  this  given  only  three  times  a  day.  She  was  left  in 
bed  for  a  fortnight  in  a  dark  room,  as  she  said  that  if  she  got 
up  she  would  get  worse.  At  the  end  of  that  time  she  was  still 
rambling,  partially  incoherent,  and  full  of  delusions,  but 
nearly  free  from  active  excitement,  and  the  medicine  was 
discontinued.     She   remained   slightly  affected   in   mind  for 


246  STATES   OF   MENTAL  ALTEENATIOK 

another  fortnight.  At  the  end  of  a  month  from  the  day  the 
excitement  began  she  was  well,  and  was  discharged  from  the 
Asylum  six  months  thereafter.  I  heard  that  she  was  still 
keeping  well  a  year  from  the  time  of  her  attack  of  mania, 
which  was  thus  cut  short  (as  it  seems  to  me)  by  bromide  of 
potassium.  I  gave  the  valerian  because  she  was  beginning  to 
menstruate  at  the  time  the  mania  began. 

It  will  be  observed  that  the  excitement  in  this  attack  only 
lasted  about  three  days,  and  she  had  never  been  less  than  two 
months  excited  at  a  time  in  her  nine  previous  attacks.  The 
aberration  of  mind  was  only  of  a  month's  duration.  It  had 
never  been  shorter  than  between  three  and  four  months 
previously,  every  symptom  of  an  ordinary  attack  being  clearly 
present  and  first ;  and  the  interval  of  sanity  has  been  even 
now  longer  than  any  such  interval  except  that  between  the 
fifth  and  sixth  attacks.  The  excitement  disappeared  as  the 
patient  showed  signs  of  coming  under  the  influence  of  the 
bromide,  and  its  constitutional  symptoms  were  developed.  I 
must  say,  however,  such  a  favourable  result  is  rare. 

I  have  now  tried  sulphonal  in  doses  of  from  20  to  40  grains 
in  three  cases  of  old  estabhshed  folie  circulaire  in  the  very 
many  cases  where  a  periodic  recurrence  of  excitement  and 
insomnia  seemed  to  be  establishing  itself,  and  the  general 
results  are  sufl&ciently  striking  to  have  left  a  very  strong 
impression  on  my  mind  in  its  favour!  The  first  case  of  folie 
circulaire  was  that  of  D.  G.  A.,  a  woman  of  37  on  her 
admission  into  the  Asylum  in  1869.  Before  that  she  had  had 
several  attacks  of  maniacal  excitement,  and  had  been  treated 
in  two  asylums.  For  twenty  years  she  had  regularly  recurring 
attacks  of  intense  maniacal  excitement  lasting  from  a  week  to 
six  weeks,  each  succeeded  by  a  week  or  ten  days  of  melanchohc 
stupor,  and  then  by  a  few  weeks  of  comparative  sanity,  and 
industrious  habits.  The  excitement  was  very  intense,  accom- 
panied by  continuous  noise,  violence,  tearing  clothing,  and 
unmanageability.  She  usually  needed  to  be  secluded  in  her 
room  for  a  few  days  at  the  height  of  each  attack.     As  time 


STATES  OF  MENTAL  ALTERNATION.  247 

went  on  the  attacks  became  on  the  whole  longer  aii4  more 
violent,  while  the  sane  intervals  were  shorter.     The  bromide 
and   cannabis  mixture  produced  a  slight   diminution  of,  the 
excitement,  while  the  effects  of  hyoscine  were  only  transient. 
The  menopause  produced  no  marked  change  in  her  condition. 
In  the  end  of  1889  we  began  the  use.  of  sulphonal  in  30  grain 
doses,  repeated  twice  or  even  thrice  a  day  till  she  got  fairly 
under  the  influence  of   the  drug,  at  the  beginning  of   each 
attack  of  excitement.     The  result  was  that   the  attack  was 
modified   at   first,  and  after   a   few  months   quite   arrested. 
Gradually  one  or  two  single  doses  were  sufficient  to  stop  an 
attack,  and  in  twelve  months  the  attacks  ceased  to  recur,  and 
she  required  no  more  sulphonal.     During  the  year  (1890)  she 
gained  continuously  in  weight,  until  she  was  three  stones  more 
in  January  1891  than  she  had  been  in  January  1890.     During 
1891  she  has  kept  quite  free  from  excitement  or  depression, 
and  has  needed  no  sulphonal.     She  was  a  quiet,  industrious 
member  of  our  community  after  her  20  years  of  recurrent 
excitement,  but  she  was  not  sane.     The  disease  seems  to  have 
undergone  a  transformation.     Instead  of  typical /oZ^e  circulaire, 
it  became  marked  monomania  of  unseen  agency,  her  delusions 
being  that  when  she  was  asleep  at  night  men  came  in  and 
thrashed  her,  and  almost  broke  her  bones,  leaving  her  sore 
all  next  day.     I  cannot,  of  course,  say  whether,  if  given  in 
the  early  stage  of  the  folie  circulaire,  during  the  menstrual 
life,  it  would  have  arrested  or  changed  the  disease.     She  was 
so  quiet  and  manageable  that  in  1894  we  recommended  her 
to  be  "boarded  out"  in  the  country.     On  leaving  the  Asylum 
she  at  once  became  violently  excited,  and  the  alternation  has 
been  set  up  again  and  we  find  sulphonal  as  yet  unavailing  to 
stop  the  periods  of  excitement. 

The  next  case  of  D.  G.  B.  was  not  so  striking,  but  the 
effect  of  the  drug  was  essentially  the  same,  in  its  tendency  to 
arrest  regular  recurrences  of  maniacal  excitement.  She  was 
admitted  to  the  Asylum  in  1847,  at  the  age  of  16,  and  from 
then  till  April  1890^that  is,  for  a  period  of  forty-three  years 


248  STATES   OF   MENTAL  ALTEENATION. 

— she  was  subject  to  regularly  recurring  attacks  of  maniacal 
excitement,  lasting  from  four  to  seven  months,  alternated 
with  periods  of  stupor  for  two  or  three  months,  and  compara- 
tive sanity  for  other  two  or  three  months.  When  excited  she 
could  not  be  managed  out  of  seclusion  all  day  for  several 
weeks.  In  April  1890,  when  beginning  an  attack,  she  was 
put  on  sulphonal  in  30  grain  doses  twice  a  day,  and  after 
getting  nine  powders  the  excitement  ceased  and  she  became 
quiet,  sensible,  and  manageable.  She  showed  occasional  ten- 
dencies to  get  excited  during  1890,  but  one  20  grain  powder 
always  had  the  effect  of  stopping  the  attack.  She  got  one 
such  powder  about  once  a  month.  The  change  in  her  was 
marvellous.  In  January  1891  she  developed  Tubercular-Peri- 
tonitis, and  died  in  February. 

Pathology. — Of  all  forms  of  mental  disease  this  is  the  one 
which  illustrates  best  the  distinction  —  often  forgotten — 
between  the  pathology  of  insanity  and  its  pathological  anatomy. 
If  we  can  show  that  from  any  hereditary,  developmental  or 
reflex  cause,  or  that  through  any  undue  or  insufficient  mental 
stimulus,  a  certain  morbid  mental  condition  is  caused,  if  we 
can  co-relate  certain  clinical  groups  of  mental  and  bodily 
symptoms  with  such  causes,  and  if  we  can  show  reason  why 
such  symptoms  are  associated  with,  and  due  to,  morbid  work- 
ing of  the  brain  cortex,  even  though  after  death  no  abnor- 
mality can  be  discovered  in  any  brain  cell,  capillary  or  lym- 
phatic, we  are  entitled  to  say  that  we  know  something  of  the 
pathology  of  the  disease.  It  implies  a  narrow  and  a  most  un- 
scientific conception  of  mental  diseases  and  of  brain  working 
to  imagine  that  gross  post-mortem  changes  are  needed,  to 
explain  all  cases  of  insanity.  It  is  a  travesty  of  the  word 
"scientific"  to  exclude  from  its  all-embracing  range  any 
possible  aspects  of  the  study  of  mental  diseases,  or  to  claim 
that  a  microscopic  and  morbid  anatomy  view  is  the  only  or 
the  chief  "  scientific  "  mode  of  studying  the  subject.  Especially 
is  this  the  case  when  we  consider  our  present  methods  and 
instruments  for  accurately  investigating  mind  and  brain  and 


STATES  OF   MENTAL   ALTEKNATION.  249 

their  co-relations.  Can  any  reasonable  man  expect  a  full 
explanation  of  those  subtile  mental,  affective,  and  moral 
changes,  from  health  to  exaltation,  from  exaltation  to  depress 
sion,  then  to  health  again,  this  alternation  going  on  for  years 
with  no  permanent  damage  to  mental  functions,  in  gross 
cellular  or  vascular  changes?  As  regards  the  pathological 
appearances  found  after  death  in  cases  of  prolonged  alter- 
nating insanity,  I  found  in  all  of  them  more  or  less  brain 
atrophy,  especially  affecting  the  convolutions,  in  all  of 
them  thickening  of  the  membranes,  in  many  of  them 
thickening  of  the  skull  cap.  One  case  who  had  been  for 
twenty -five  years  ill,  showed  an  amount  of  deposit  of  bone  on 
the  inner  table  of  the  skull  I  have  never  seen  exceeded  (see 
Plate  YI.).  In  most  of  them  there  was  vascular  disease,  and 
in  one  or  two  cases  local  disintegrations  from  emboHsms  and 
other  results  of  blood-starvation.  In  short,  I  found  the 
common  pathological  appearances  in  cases  of  chronic  insanity, 
but  with  no  special  pathology  whatever.  No  doubt  such  a 
deposit  as  that  figured  in  Plate  VI.  is  secondary  and  partly 
compensatory  for  the  brain  atrophy,  but,  like  many  of  the 
changes  of  structure  in  the  bones  and  membranes,  the  vessels 
and  lymphatics,  the  neuroglia,  and  the  epithelium  of  the 
brain  in  chronic  insanity,  it  is  very  instructive  in  the  light  it 
sheds  on  the  pathology  of  the  disease.  If  the  intensity  of  the 
morbid  action  was  so  great  even  in  the  bones,  as  to  cause 
such  secondary  changes,  how  great  must  it  have  been  in  the 
convolutions,  its  primary  seat !  That  skull  cap  is  a  vivid 
object  lesson,  which  rightly  interpreted,  enables  us  better 
to  realise  the  dynamic,  trophic  and  vascular  conditions  within 
the  skull  during  life,  when  the  brain  cells  are  in  a  state 
of  maniacal  exaltation. 


LECTUEE   VI. 

STATES  OF  FIXED  AND  LIMITED  DELUSION 
{3I0N0MANIA,    MONO-PSYCHOSIS,    PARANOIA.) 

"  Delusion,"  popular  and  medical  use  of — Delusion  from  want  of  judg- 
ment in  idiots  and  imbeciles — Religious  Delusions,  visions,  voices, 
hypersesthesia  of  special  sense  centres — Delusions  from  ignorance 
and  superstition — False  sense  impressions  transmitted  to  brain — 
Sleep  and  Dreaming  and  Nightmare — Definition  of  "  Insane  De- 
lusion " — Fixity  or  not  of  Delusion  important — No  pure  Monomania 
— Delusional  states  commonly  associated  with  some  enfeeblement 
(Dementia) — Types  most  Common  :  Of  Pride  ;  of  Unseen  Agency  ; 
of  Suspicion  ;  two  last  sometimes  associated  with  first ;  "  megalo- 
mania"— Infinite  variety  of  Delusions  and  subjects  of  Delusion — 
Jlfo7iO??ia7i,m  usually  incurable — How  it  arises;  1.  Out  of  temperament 
and  disposition  ;  2.  After  acute  mania  and  melancholia ;  3.  From 
brain  poisoning  by  alcohol,  or  after  traumatic  injury  ;  4.  From 
perverted  or  misinterpreted  sensations — Legal  importance  of  De- 
lusion ;  importance  for  Diagnosis  and  signing  Certificates  of 
Insanity;  "harmless"  and  "dangerous"  delusions.  Treatment: 
Change  ;  distract  mind  by  new  ideas,  new  pleasures,  new  work  ; 
correction  of  any  bodily  disorder,  or  any  cause  of  irritation ;  an 
asylum.  Prevention:  Counteract  temperament  and  morbid  dis- 
position by  reason  and  good  principles  and  habits  ;  suitable  choice 
of  occupation  ;  temperance  in  all  things  ;  cheerful  family  life  ;  work 
body  rather  than  brain.  Paranoia :  German  origin  of  name — Want 
of  clear  definition — Variety  of  forms — Hereditary— Slow  evolution 
•   — Abnormal  reactions — Dangers — Social  effects. 

The  study  of  this  form  of  mental  aberration  should,  like  that 
of  every'  other  form,  be  begun  from  a  physiological  point  of 
view.  There  are  all  sorts  of  false  sense  impressions  and  false 
intellectual  beliefs  which  are  consistent  with  sanity  and  due 
to  physiological  laws.     When  a  hght  is  rapidly  intermittent 


STATES   OF  FIXED  AND   LIMITED   DELUSION.  251 

and  appears  to  the  eye  to  be  continuous,  when  the  sensation 
of  the  toes  and  their  movements  are  felt  in  an  amputated 
stump,  and  when  one  is  deceived  by  the  quick  movements  of 
a  juggler,  we  have  sense  delusions  produced.  When  through 
brain  fatigue,  brain  poisoning,  or  disturbance  of  the  circulation, 
objects  are  seen  double ;  or  when  the  old  impressions  on  the 
perceptive  centres  of  the  brain  are  projected  and  appear  to  be 
seen  as  real  objects,  the  true  nature  of  which  have  to  be  ascer- 
tained by  the  judging  faculty,  we  have  real  hallucinations, 
but  not  insane  hallucinations.  The  whole  mental  life  of  a 
child  in  its  very  early  years,  before  its  senses  are  trained  or  its 
judging  power  developed,  is  one  series  of  delusions.  The 
superstitions  of  the  ignorant  are  delusions,  but  they  result 
from  lack  of  training  and  want  of  development  of  the  judging 
power,  not  from  a  diseased  perversion  of  it.  When  lately  a 
great  part  of  the  Mohammedan  population  of  Constantinople 
turned  out  one  night,  and  with  frantic  gesticulations,  great 
shouting,  and  firing  of  guns,  tried  to  frighten  away  a  beast 
which  they  believed  to  be  devouring  the  moon  when  it  was 
eclipsed,  they  laboured  under  a  delusion  of  ignorance.  I  have 
heard  a  perfectly  sane  but  ignorant  woman  in  Cumberland  say 
that  every  time  she  had  sat  by  the  bedside  of  a  dying  person, 
she  had  heard  the  "  Death  Clock  "  in  the  wall,  and  whenever 
she  heard  that,  she  knew  the  patient  was  going  to  die,  and  as 
to  this  she  had  never  been  deceived.  You  meet  with  people 
who  believe  that  certain  things  are  going  to  happen  on  utterly 
absurd  grounds,  and  so  labour  under  delusions  in.  a  popular 
sense.  Dreaming  and  nightmare  give  you  the  best  idea  of  an 
insane  delusion,  and  are  the  nearest  physiological  counterparts 
of  it.  A  sufficient  amount  of  fatigue  and  exhaustion  from 
want  of  sleep  wiU  produce  a  condition  in  almost  any  brain 
that  is  closely  allied  to  that  of  the  monomaniac. 

Such  "  delusions "  have  little  relationship  practically  to 
"insane  delusions,"  however  much  they  may  resemble  them 
in  certain  respects,  or  however  much  they  may  be  psycho- 
logically alhed  to  them.     The  delusions  that  are  really  half- 


252  STATES   OF   FIXED   AND    LIMITED   DELUSION. 

way  house  between  those  I  have  referred  to  and  the  true 
insane  dehisions,  are  the  false  behefs  of  imbeciles,  and  the 
temporary  delusions  of  persons  whose  emotions  have  been 
strongly  roused  by  religious  services  or  contemplation,  so  that 
they  see  visions  or  hear  voices.  The  imbecile  has  deficient 
judging  power  from  want  of  brain,  development,  and  often 
has,  in  addition,  morbid  energising  of  his  convolutions.  His 
delusions  have  often  to  be  treated  as  insane  delusions,  as  when 
he  imagines  he  is  married  to  a  woman  and  wants  to  act  on  his 
belief,  or  when  he  thinks  his  neighbour's  property  is  his  own, 
and  proceeds  to  use  it.  To  us,  as  practitioners  of  medicine, 
the  "insane  delusion"  is  the  one  that  affects  the  conduct  or 
life,  provided  it  results  from  a  morbid  condition  of  brain, 
either  through  deficiency  or  disease.  The  education,  age,  class, 
and  even  race,  in  some  degree  determine  whether  any  given 
false  belief  is  an  insane  delusion  or  not.  The  whole  subject 
of  false  sense  perceptions,  sane  hallucinations,  unreasoning 
unfounded  "  instincts  "  about  things,  is  most  interesting  both 
from  the  physiological  and  medico-psychological  side. 

Definition. — An  "  insane  delusion  "  may  therefore  be  defined 
to  be  "  a  behef  in  something  that  would  be  incredible  to  people 
of  the  same  class,  education,  or  race  as  the  person  who  expresses 
it,  the  behef  persisting  in  spite  of  proof  to  the  contrary,  this 
resulting  from  diseased  working  of  the  brain  convolutions." 

Ulusirative  Cases. — There  was  once  an  old  gentleman,  D.  L., 
a  patient  in  Morningside  Asylum,  who  in  liis  manners  and 
conduct  was  all  that  was  gentlemanly,  in  his  emotional  nature 
was  benevolent  to  a  high  degree,  and  in  his  dress  and  deport- 
ment exhibited  no  pecuharity  whatever,  but  who  calmly 
asserted  that  he  was  many  thousand  years  old ;  that  he  had 
known  I^oah  rather  intimately,  and  found  him  a  most  sociable 
man,  but  "  a  httle  too  fond  of  his  toddy  " ;  that  he  once  went 
out  snipe-shooting  with  King  David,  who  was  a  crack  shot ; 
and  one  day  gave  St  Paul  a  lift  in  his  gig  on  the  Peebles 
road.  I  once  had  a  patient,  D.  M.,  at  the  Carhsle  Asylum, 
who  was  acute  intellectually  and  morally  irreproachable,  but 


STATES   OF   FIXED   AND    LIMITED   DELUSION.  253 

who,  ever  after  a  hemiplegic  attack,  believed  that  twice  two 
was  not  four,  but  four  and  a  quarter,  and  who  spent  his  whole 
time  not  devoted  to  keeping  the  Asylum  accounts — wliich 
he  did  accurately  on  the  "  old  system "  in  deference  to 
the  steward's  prejudices — to  making  elaborate  calculations  by 
his  own  mode  of  arithmetic  as  to  the  distances  of  the  stars,  a 
new  system  of  logarithms,  constructing  new  quadrants,  &c. 
His  manuscripts,  which  filled  two  large  chests  at  his  death,  he 
solemnly  left  by  will  to  the  University  of  Oxford.  In  both 
these  cases  there  was  no  trace  of  the  morbid  mental  depression 
or  exaltation  that  I  have  described.  The  delusions,  which 
were  perfectly  fixed  and  unchanging  from  year  to  year  during 
the  lifetime  of  the  patients,  really  constituted  the  insanity. 
They  were  examples,  therefore,  of  delusional  insanity  or 
monomania.  There  are  very  few,  if  any,  examples  of  a  pure 
monomania^ — that  is,  of  a  person  who  has  one  single  delusion 
and  that  alone.  The  ordinary  form  of  this  type  of  mental 
disturbance  is  for  the  delusions  of  the  patient  to  refer  to  one 
particular  subject  or  set  of  subjects,  or  for  him  to  be  morbid 
in  a  particular  direction  of  intellect  or  feeling,  while  he  is 
sound  in  most  directions.  The  chief  directions  such  delusions 
take  are  of  unreal  greatness,  unseen  and  impossible  agencies, 
unfounded  suspicions  and  fears,  constituting  the  tliree  varieties 
of  monomania  : — 

a.  Monomania  of  grandeur  or  pride. 
h.  Monomania  of  unseen  agency. 
c.  Monomania  of  suspicion. 

Monomania  of  Grandeur  or  Pride — The  Rightful  King  of 
England. — Here  is  a  pauper  patient,  D.  X.,  who  believes 
himself  to  be  the  rightful  king  of  England.  He  looks  sane, 
and  is  perfectly  quiet  and  self-possessed  in  manner.  He  is  a 
well-developed  man,  far  above  the  average  of  his  class  in 
general  looks  and  in  facial  expression.  He  told  us  his  story 
.  with  perfect  calmness  and  coherence,  rather  apologetically, 
and  saying  he  knew  we  would  probably  not  believe  him  if  he 


254  STATES   OF   FIXED   AND   LIMITED  DELUSION.  ■' 

said  he  was  heir  to  the  throne.  Then  when  he  came  to  tell 
about  his  betrothal  at  thirteen  to  Queen  Victoria  (I  have  had 
a  score  of  patients  who  were  to  have  been  married  to  Her 
Majesty),  and  Prince  Albert's  adroitly  shpping  in,  he  got  on 
to  ground  purely  imaginary  and  delusional.  The  whole  story 
was  a  queer  mixture  of  wholly  imaginary  premisses  and  much 
sound  but  also  much  unsound  conclusions  from  them. 

Reasoning  of  the  Insane. — Insane  people  generally  do  not 
reason  rightly  from  wrong  premisses,  as  Locke  said,  but  some 
of  them  do.  The  simply  delusional  and  the  melancholic  cases 
are  usually  the  classes  who  approach  nearest  to  this  descrip- 
tion. It  is  most  difficult,  if  you  beheved  his  case  is  incurable, 
to  pick  a  flaw  in  the  reasoning  of  a  melanchohc  who  says,  "  I 
am  miserable  and  incurably  ill,  and  shall  get  worse,  and  lose 
what  reason  I  have  got.  I  believe  all  such  people  are  better 
out  of  the  way.  I  have  all  my  life  believed  this,  therefore  I 
mean  to  put  an  end  to  myself  as  soon  as  possible."  One 
premiss  is  correct,  and  the  other  was  held  by  him  to  be  so 
when  he  was  quite  sane,  and  is  held  by  many  sane  people. 
But  in  the  case  of  the  monomaniac,  one  of  his  premisses  is 
indubitably  wrong  in  the  estimation  of  all  sane  people,  but 
you  cannot  convince  him  of  this.  If  twice  two  had  made 
four  and  a  quarter,  as  D.  M.  said  it  did,  then  he  was  quite 
right  to  have  devoted  every  spare  moment  of  his  life  to  the 
demonstration  that  the  world  had  fallen  into  a  serious  error, 
and  to  working  out  a  new  system  of  astronomy  and  logarithms 
on  a  correct  basis.  D,  N.,  the  king,  is  an  excellent  black- 
smith, and  we  get  him  to  work  at  his  trade  in  our  shop. 
Nowadays  we  do  not  allow  our  monomaniacs  or  insane  people 
generally  to  dress  themselves  or  to  look  like  what  they  beheve 
themselves  to  be,  as  they  did  of  old.  The  antipathy  to 
individuahsm  which  affects  society  in  every  direction  is  strong 
in  asylums  for  the  insane.  "We  now  discourage  those  outward 
manifestations  of  insane  delusions  that  used  to  give  a  lunatic 
asylum  its  most  striking  character.  The  monarchs  crowned 
with  straw,  the  duchesses  in  gaudy  spangles,  the  field-marshals 


STATES   OF   FIXED   AND   LIMITED   DELUSION.  255 

with  grotesque  military  uniforms,  that  could  be  seen  in  any 
asylums  of  old,  you  will  not  now  see  when  you  go  through 
our  wards.  If  the  man  with  the  millions  of  money,  who  is 
the  rightful  heir  to  the  throne,  affixes  the  top  of  a  soda-water 
bottle  to  the  front  of  his  cap  as  a  faint  symbol  of  his  position, 
it  is  at  once  unfastened.  If  the  princess,  who  is  the  greatest 
beauty  in  Europe,  bedecks  herself  too  conspicuously  with  bits 
of  coloured  glass  and  in  conspicuous  ribbons,  they  are  quietly 
removed  at  night.  The  insane  man,  hke  his  sane  brother,  in 
most  cases  soon  adapts  himself  to  his  circumstances,  and 
submits  to  rule  and  public  opinion.  Half  the  discipline  of 
asylums  is  directed  against  insane  appearances,  habits,  and 
ways.  By  suggestion  those  would  daily  strengthen  delusions 
and  would  confirm  evil  habits  if  uncorrected.  The  last  of  the 
great  characters  of  the  older  period  of  this  Asylum,  D.  0.,  lived 
on  into  the  present  regime,  and  was  allowed  to  wear  the 
insignia  of  his  rank,  but  I  have  allowed  no  successor  to  arise. 
He  was  the  "King  of  kings,"  and  wore  a  most  elaborate 
crown  of  many  colours,  each  part  of  which  had  a  symbolic 
meaning.  He  was  so  picturesque  a  character  about  the.  place, 
and  was  so  striking  a  clinical  illustration  of  monomania  of 
grandeur,  and  withal  so  harmless  and  useful  in  the  garden, 
that  I  never  ordered  him  to  be  discrowned.  He  had  certain 
visions  from  heaven  which  he  reduced  to  concrete  forms  in 
drawings  and  pohshed  stones,  and  his  relations  with  Queen 
Victoria  were  most  intimate.  One  "  cloud  of  the  Lord  "  which 
he  once  saw  on  the  top  of  St  John's  Church,  had  taken  most 
vivid  hold  on  his  imagination,  for  he  cut  Hkenesses  of  it  on 
the  bark  of  almost  every  large  tree  in  the  Asylum  grounds, 
where  they  will  remain  for  perhaps  hundreds  of  years.  The 
tendency  to  symboHsm  and  morbid  outward  decoration  is  much 
stronger  in  the  Celtic  races  than  in  the  Teutonic,  and  in  the 
female  than  in  the  male  sex.  In  the  Highland  asylums  it  is 
almost  impossible  to  make  the  patients  abandon  their  conceits 
in  dress.  Such  changes  have  their  drawbacks,  for  no  Dean 
Eamsay  of   the  future  will  be  able   to  compile   for  us  such 


256  STATES  OF   FIXED   AND   LIMITED  DELUSION. 

delightful  stories  of  our  fools,  and  our  writers  and  artists  will 
have  to  look  out  for  less  striking  environments  for  their  mad- 
men than  fools'  caps  and  gewgaws,  or  chains  and  filth. 

Hallucinations  of  the  senses  are  very  common  in  tliis  whole 
class,  and  also  delusions  as  to  the  identity  of  the  persons 
around  them.  I  have  a  gentleman  patient  who,  whenever  he 
goes  into  Edinburgh,  meets  the  late  Emperor  of  the  Erench, 
or  the  late  Prince  Consort.  So  marked  is  this  tendency  in 
some  cases  that  it  might  be  called  a  special  form  of  mono- 
mania, that,  namely,  of  mistaken  identity.  It  is  well  illustrated 
in  this  letter  of  D.  0.  A. : — 

"My  Dear  Mama, — I  have  been  long  in  answering  your  last  kind 
letter,  but  the  real  reason  is  that  I  have  been  always  so  scarce  of  news 
to  give  you  that  I  could  never  make  up  my  mind  to  sit  down  and  write  ; 
indeed,  I  cannot  say  that  I  have  anything  to  say  at  present.  I  was  out 
on  Saturday  seeing  Signer  Bosco's  magical  entertainment  in  the  Masonic 
Hall.  I  think  I  will  just  tell  you  all  my  ideas  about  the  people  here,  as 
I  do  not  think  that  they  are  fancies  of  my  own.  Old  Captain  G.,  surgeon 
of  Uncle  T.'s  dragoon  regiment,  is  here;  he  calls  himself  Dr  S.,  but  I 
don't  mind  that. 

"  Sir  J.  H.  is  here  too,  calling  himself  J.  S.  '  With  frisking  airs  Miss 
pussy  tries  the  power  of  she's  gooseberry  eyes  to  win  the  heart  of  every 
swain.'  He  is  attendant  on  a  Mr  Y.,  whom  I  have  no  reason  to  doubt 
now  is  a  brother  of  the  operatic  singer  that  the  Duke  of  Cambridge  shot 
in  the  theatre  at  Vienna.  I  am  positive  that  I  saw  Sir  A.  in  the 
Meadows  without  his  case  of  false  teeth.  Emperor  Yea  of  China  is  here 
too,  calls  himself  Mr  B.  ;  he  is  kept  by  a  son  of  Lord  C.  Peter  D.  is 
head  gardener  here  ;  he,  his  wife  and  family  live  at  the  lodge  at  the  gate 
on  the  road  out  to  Comiston.  S.  D.  is  here  on  the  ground  flat ;  I  think, 
when  I  recollect  right,  you  put  that  idea  into  my  head  out  at  P.  He  is 
attended  by  Malcolm,  a  son  of  Abraham  Lincoln's.  He  writes  squibs 
in  the  papers  about  the  'Solo'  royal  family.  He  gets  the  papers  printed 
over  at  the  asylum  press  for  my  use,  but  I  never  read  them.  Maggie 
F.'s  brother  is  also  one  of  the  attendants  here.  Bell,  the  brother  of  the 
Private  Bell  of  the  5th  D.  G,,  is  here  acting  as  general  scogey.  He  is 
the  man  that  J.  bought  Wasp  from.  The  matron  of  the  East  House 
here  is  a  sister  of  my  attendant's ;  they  are  both  children  of  Lord  C, 
and  their  mother  is  the  cook  to  the  East  House.  Abraham  Lincoln's 
\\'ife  is  here,  kept  by  Miss  D.  Wilkes  Booth  and  Miss  Reynolds, 
Gregorj',  Mag  Wallace  and  old  Armstrong  son  is  head  attendant  of  the 
male  wing,  East  House. 

"  Kind  love  to  you  all,  and  I  remain,  my  dear  edie, 

"  Your  most  afifec.  son,  D.  0.  A." 


STATES   OF  FIXED   AND   LIMITED   DELUSION.  257 

"Am  I  in  a  trance  again  when  I  say  that  you  really  cooked  and  eat 
the  meat  which  came  off  my  head  ? " 

But  to  return  to  D.  IS".,  who  may  be  taken  as  a  typical  case 
of  monomania  of  grandeur.  His  mind  is  not  only  affected  by 
the  delusion  that  he  is  king,  but  it  is  affected  by  a  tendency 
to  unreal  elevation  in  all  directions,  and  it  is  also  now  some- 
what enfeebled,  as  is  commonly  the  case  after  many  years  of 
such  a  state.  He  often  writes  me  long  rambling  letters,  pro- 
posing various  impracticable  modes  of  managing  the  Asylum, 
and  he  is  the  greatest  fault-finder  in  it.  Then  affectively  he  is 
different  from  a  sane  man,  showing  small  love  for  his  wife 
or  children,  and  he  takes  morbid  dislikes  to  people  without 
real  cause.  He  once  went  down  to  Leith  to  see  his  family, 
and  went  to  all  the  houses  of  a  certain  street  wliich  he 
imagined  belonged  to  him,  and  gave  the  inhabitants  due 
notice  to  quit  at  the  next  term  !  He  is,  of  course,  very 
inconsistent  to  work  as  a  blacksmith,  he  being  a  king;  but 
the  conduct  of  by  far  the  majority  of  the  insane  is  quite 
inconsistent  with  their  beliefs ;  and  then  if  he  did  not  work, 
he  would  get  no  tobacco  or  beer  to  lunch,  arguments  that  even 
royalty  can  appreciate.  Sometimes  the  kings  and  cases  of 
monomania  of  grandeur  will  not  occupy  themselves  in  common 
occupations.  I  have  a  "  prophet  of  the  Lord,"  D.  0.  B.,  a 
joiner,  who  by  no  means  at  our  disposal  can  be  got  to  work  at 
his  trade.  He  says  the  Lord  has  set  him  a  new  work,  and  he 
must  follow  it.  He  sees  visions  from  God  all  the  time,  which 
he  puts  down  on  paper,  green  and  blue  angels,  sapphire 
prophets,  &c.  He  will  go  to  no  amusements,  nor  to  church. 
I  have  another  man,  D.  0.  C,  with  almost  precisely  the  same 
delusions — viz.,  that  he  is  a  "Man  of  God" — who  is  a  capital 
worker  in  the  garden,  and  enjoys  a  dance  or  a  concert 
immensely.  The  mental  disease  in  D.  IST.  first  appeared 
tliirty-four  years  ago  as  an  attack  of  melancholia,  from  which 
he  recovered  in  four  weeks,  and  the  present  attack  began 
twenty-nine  years  ago,  also  with  an  attack  of  melanchoHa, 
which,  as  it  passed  away,  left  Mm  in  his  present  condition. 

K 


258  STATES   OF  FIXED  AND   LIMITED  DELUSION. 

There  is  a  strong  heredity  to  insanity  in  his  family,  his 
brother  having  been  a  melanchoHc  and  committed  suicide; 
and  his  eldest  daughter,  D.  0.  D.,  has  been  a  patient  here 
since  she  was  twenty -two,  being  now  a  case  also  of  monomania 
of  grandeur,  and  beheving  herself  to  be  a  princess;  her 
insanity  beginning  with  melanchoha.  She  is  like  her  father 
in  face  and  complexion,  but  was  begotten  when  he  was  sane, 
when  therefore  his  disease  was  with  him  a  mere  potentiahty. 
But  this  is  often  seen.  That  law  of  neurotic  heredity,  through 
which  in  each  successive  generation  the  neurosis  appears  at  an 
earher  age  than  in  the  preceding  one,  was  .exemphfied  in  this 
case,  for  the  father  was  thixty-three  when  he  first  became  in- 
sane, the  brother,  who  committed  suicide,  thirty-two,  while  the 
daughter  was  only  twenty-two.  The  tendency  towards  early 
developmental  dementia  that  is  usually  seen  in  such  strongly 
hereditary  cases  if  they  do  not  recover,  is  shown  here,  for  along 
with  her  delusional  condition  she  is  also  ■  much  more  mentally 
enfeebled  than  her  father,  not  being  able  to  employ  herself, 
not  taking  interest  in  anytliing,  and  having  httle  mental  vigour 
or  spontaneity. 

A  Distinguished  Assemblage. — In  addition  to  the  cases  I 
have  mentioned,  I  am  able  to  present  to  you  some  of  the 
most  remarkable  personages  that  have  ever  Hved.  Here  is 
Jesus  Christ,  and  here  are  the  Prophet  Ehas,  the  Emperor  of 
the  Universe,  the  Universal  Empress,  the  Empress  of  Turkey, 
the  only  daughter  of  God  Almighty,  Queen  Elizabeth,  four 
kings  of  England,  one  king  of  Scotland,  the  Duke  of 
Ealmarnock,  the  inventor  of  perpetual  motion,  a  man  who  has 
discovered  the  "  new  ehxir  of  life  "  that  can  cure  delusions, 
twelve  persons  to  Avhom  this  establishment  and  all  that  it 
contains  belongs,  a  lady  who  daily  and  nightly  has  delightful 
conversations  with  the  Prince  of  Wales  and  the  rest  of  the 
Eoyal  family,  a  man  who  is  to  renovate  humanity,  and  cure  all 
our  existing  ills  by  means  of  a  scheme  he  has  in  his  head. 
The  gentleman  who  has  discovered  the  "new  elixir  of  life" 
wrote  out  an  advertisement  setting  forth  its  infallible  virtues 


STATES  OF  FIXED   AND   LIMITED   DELUSION.  259 

that  woiUcI  have  done  credit  to  the  most  successful  patent 
medicine  proprietor.  He  used  to  make  it  up  in  the  Asyhim, 
and  wanted  much  to  try  it  on  the  patients,  but  none  of  them 
beheved  in  him  or  would  take  his  nostrum.  But  he  was 
allowed  to  go  out  for  a  walk  into  town  occasionally,  being  a 
harmless  man,  and  I  found  that  he  used  to  take  a  f.ew  of  his 
bottles  with  him,  and  sometimes  sold  them  at  five  shillings  a 
piece^ — this  monomaniac — to  sane  citizens  of  Edinburgh! 

Those  all  are  calm  and  cheerful  people,  some  of  them 
bearing  themselves  in  their  deportment  and  manner  as  become 
such  distinguished  personages,  though  a  few  do  not  exhibit 
any  indications  of  their  greatness  in  appearance  or  gait,  and  all 
are  absolutely  unmoved  by  the  most  conclusive  argument  or 
evidence  that  their  ideas  are  wrong  and  unfounded.  They 
all  looked  on  me  as  the  fool  to  be  pitied  or  contemned,  who 
could  not  see  their  greatness.  They  were  all  in  good  bodily 
health,  and  all  looked  as  if  they  would  hve  as  long  as  any 
of  us. 

Physiological  Foundation  of  Monomania. — In  considering 
the  origin  of  this  form  of  mental  aberration,  we  see  that  all 
tliis  imaginary  grandeur  and  power  has  a  physiological  foun- 
dation in  the  brain- working  of  every  man.  The  wildest  of 
those  beliefs  are  not  half  as  extravagant  as  the  day-dreams, 
imaginations,  fancies,  castles  built  in  the  air,  and  longings  of 
nearly  every  man  and  woman.  And  in  comparison  to  the 
imaginings  or  even  the-  behef  s  of  a  child,  they  are  tame.  Com- 
pared with  the  dreams  of  most  men,  they  are  very  reasonable 
indeed.  It  is  easy  to  conceive  how  the  brain  of  a  man_ 
with  an  heredity  to  insanity,  of  unstable  constitution,  of  a 
proud  imaginative  disposition,  would,  when  it  became  dis- 
ordered in  working  from  any  cause,  readily  play  its  owner  the 
trick  of  making  him  believe  his  day-dreams  and  longings  to  be 
reahties.  Once  impair  the  judging  power  that  enables  us  to 
compare  and  estimate  facts,  and  we  should  all  be  kings  or  very 
great  men  at  once. 

Sometimes  the  monomania  of  grandeur  is  combined  with 


260  STATES   OF   FIXED  AND  LIMITED  DELUSION. 

that  of   suspicion  and  persecution — the  megalomania  of   the 
French. 

Monomania  of  Unseen  Agency. — Another  marked  type  of 
dehisional  insanity  is  that  of  unseen  agency.  Such  patients 
beheve  that  they  are  electrified,  that  they  are  mesmerised, 
that  noxious  gases  are  blown  into  their  bedrooms,  that  people 
speak  to  them  and  call  them  bad  names  through  walls,  by 
telephones,  and  out  of  the  ground,  that  spirits  and  devils 
haunt  them,  that  persons  come  to  them  at  night  and  break 
their  bones  or  ravish  them,  that  persons  read  their  thoughts, 
or  have  power  over  them  to  act  on  their  thoughts.  Most  of 
those  delusions  imply  a  sense  of  ill-being  on  the  part  of  the 
patient,  or  pain  or  discomfort,  the  origin  of  which  they 
misinterpret,  I  had  a  woman  who  for  long  beheved  the 
devil  was  inside  her.  At  the  point  where  she  said  he  was, 
I  discovered  a  cancerous  tumour,  of  which  she  died  in  a  few 
months.  This  was  merely  assigning  an  insane  and  impossible 
cause  for  a  real  pain  which  she  felt.  Such  cases  are  common. 
One  of  the  most  typical  examples  of  delusions  of  being 
affected  by  electricity — and  this  and  mesmerism  are  the  two 
most  common  of  all  unseen  agencies  of  which  the  insane  com- 
plain— was  that  of  a  woman,  D.  0.  E.,  who  at  sixty-four 
became  possessed  with  the  delusion  that  people  were  electri- 
fying her  at  night.  This  idea  came  on  gradually,  with  a  little 
depression  at  first,  until  it  made  her  life  an  evident  burden  to 
her,  unfitted  her  for  all  work,  and  she  accused  her  neighbours 
of  "  working  the  electricity  "  on  her  when  she  was  sent  to  the 
Asylum.  We  found  she  had  had  heart  disease,  accompanied 
evidently  by  angina.  The  pain  of  this  she  attributed  to  people 
electrifying  her.  This  continued,  and  got  worse,  till  her  death 
of  the  heart  disease.  Living  a  solitary  life  tends  to  bring  out 
such  delusional  conditions.  I  have  a  case  now  with  "  a  big 
serpent  inside,"  in  whom  the  delusion  originates  in  angina.  It 
is  more  common  to  have  delusions,  and  not  to  be  able  to  trace 
out  such  obvious  causes  as  those  two  cases.  All  constitutional 
diseases,  such  as  cancer,  tuberculosis,  rheumatism,  alcohoHsm, 


STATES   OF   FIXED   AND   LIMITED   DELUSION.  261 

and  especially  sypliilis,  which  cause  brain  anaemia,  and  local 
disturbances  and  pains,  may,  in  a  person  whose  brain  is  pre- 
disposed to  mental  disturbance,  cause  delusions  of  unseen 
agency.  Dr  Hugh  G.  Stewart  long  ago  described  certain 
syphilitic  cases  who  imagined  that  noxious  gases  were  blown 
into  their  rooms  at  night,  or  driven  into  their  nostrils.  To 
prevent  this  they  stopped  the  keyholes  of  their  doors  at  night, 
plugged  their  nostrils  and  ears,  or  wrapped  their  heads  up.  I 
have  met  with  many  such  patients.  It  is  evident  that  there  is 
a  general  sense  of  organic  discomfort  in  such  men,  which  is 
misinterpreted  into  those  delusions.  Frequently  the  chronic 
irritation  of  the  drunkard's  stomach  is  attributed  by  him  to 
living  animals  inside,  or  to  poison.  I  once  had  a  patient,  D.  P., 
who  had  been  a  great  drunkard,  and  had  had  many  attacks  of 
acute  alcohohsm,  who  said  he  had  mice  inside  him,  gnawing 
and  running  about.  He  was  gradually  cured  or  recovered  in 
about  two  years,  under  a  teetotal  regimen,  bismuth,  easily 
digested  food,  and  fresh  air.  I  give  here  the  letter  of  a 
syphilitic  case,  D.  Q. : 

"Forced  dreaming,  forced  vomiting  from  the  stomach,  forced  glut 
vomiting  from  the  throat,  cold  shivering  by  the  forced  thinking,  sweat- 
ing done  in  the  same  way,  pains  in  the  stomach  any  way  they  think. 
I  think  it  is  time  that  this  way  of  punishing  should  be  stopped,  and  let 
me  know  if  there  is  anything  going  to  be  done  for  my  benefit  ;  and  I 
want  to  see  about  bad  usage.  I  think  it  was  time  it  was  stopped.  I 
would  thank  you  to  let  me  know  the  real  truth. — I  am,  &c." 

This  man  was  an  old  soldier,  and  had  on  admission  all  the 
appearance  of  the  syphilitic  cachexia.  He  used  to  talk  con- 
stantly about  his  delusions,  and  was  rather  dangerous,  but  now, 
after  five  years,  he  never  mentions  them  except  he  is  spoken  to 
about  them,  and  in  fact  scarcely  speaks  at  all.  His  bodily 
health  is  much  improved,  and  he  works  in  the  garden  every 
day.  The  following  letter  was  written  to  me  by  a  man,  D.  R., 
who  was  very  dangerous  indeed  from  his  delusions,  often 
threatening  to  kill  me,  and  he  afterwards  said,  often  seriously 
deliberating  whether  he  would  do  so  or  not : 


262  STATES   OF   FIXED   AND   LIMITED   DELUSION. 

"  1st  April  1S68. 

"Mr  Clouston, — I  now  take  the  opportunity  of  writing  you  these 
few  lines  to  let  you  know  that  I  am  q^uite  well  in  health,  but  j^ou  have 
punished  me  sore,  and  I  do  not  know  what  it  is  for.  A  week  or  two 
after  I  came  here  you  let  me  alone,  and  then  you  started  and  did  wrong 
with  me,  and  all  your  attendants  had  some  stuff  to  stifle  me  with.     I 

think  it  is  a  disgraceful  affair,  and  John very  nearly  choked  me. 

Some,  too,  at  the  table,  for  I  think  you  have  them  put  on  to  do  so,  and 

in  the  bedroom  there  is  Adam ,  for  I  have  catched  him,  and  told 

him  about  it.  On  the  18th  of  February  you  crushed  my  breast,  and  on 
the  20th  you  crushed  my  left  side  in.  I  thought  you  had  done  for  me, 
and  on  the  21st  February  you  crushed  the  right  side  in.  And  the  curious 
conversations  you  have  been  making  with  me  at  nights.  It's  a  shame 
and  a  disgrace.  You  ought  not  to  try  to  kill  me  altogether.  I  have 
stood  bad  treatment  that  would  have  killed  ten  men,  and  you  ought  to 
put  a  stop  to  it,  for  I  have  done  no  wrong,"  &c. 

Find  out  a  Bodily  Cause  for  Delusion. — This  man,  D.  R., 
seemed  in  perfect  bodily  health.,  and  I  could  not  discover  any 
peripheral  causes  for  the  painful  sensations  he  probably  had,  and 
which  he  so  misinterpreted.  But  in  every  case  I  advise  you  to 
examine  carefully  into  the  condition  and  working  of  all  the 
great  organs  and  functions,  the  history  of  the  patient,  to  find 
out  whether  there  has  been  syphihs  or  rheumatism,  or  other 
constitutional  disorder.  Try,  in  fact,  to  discover  a  bodily  basis 
for  the  delusions.  Such  delusions  of  unseen  agency  are  often 
associated  with  hallucinations  of  hearing.  Patients  fancy  that 
people  whisper  tlirough  floors  and  down  chimneys.  One  patient 
I  had  was  tormented  by  people  speaking  down  her  chimney, 
another  was  constantly  annoyed  by  people  talking  to  him  through 
telephones,  and  a  man  who  had  been  a  heavy  drinker,  and  had 
acute  alcoholism  several  times,  said  he  was  constantly  subjected  ■ 
to  a  process  which  he  called  "  ric-me-tic."  That  persons  read 
their  thoughts  and  influence  their  thoughts  are  very  current 
delusions.  Patients  almost  always  complain  most  of  unseen 
agencies  at  night,  just  as  they  have  hallucinations  most  at  nights 
when,  there  being  no  conflicting  real  impressions  on  the  senses, 
the  brain  is  most  anaemic,  and  is  acting  at  its  lowest  point,  the 
season,  in  fact,  of  fears  and  superstitions.     Macbeth  diu^ing  the 


STATES   OF   FIXED   AND   LIMITED   DELUSION.  263 

day  was  a  man  not  "taint  with  fear,"  but  at  night  "mine  eyes 
are  made  the  fools  o'  the  other  senses."  "  How  is't  with  me 
when  every  noise  appals  me  ? "  It  is  very  common  for  women 
to  have  the  delusion  that  they  are  made  insensible  and  ravished 
at  nights.  One  can,  of  course,  more  readily  understand  the 
explanation  of  such  delusions  than  of  others. 

I  am  told  it  is  very  common,  indeed,  for  criminals  under- 
going solitary  confinement  in  penal  servitude  to  have  delusions 
that  they  are  worked  on  by. electric  batteries.  Their  weak 
degenerate  brains,  natural  suspicions,  ignorance,  and  the  occa- 
sional use  of  the  electric  battery  to  detect  imposture  among 
them,  seem  to  account  for  this.  I  once  had  such  a  man  sent 
from  Broadmoor  Criminal  Asylum  to  the  Carlisle  Asylum  at 
the  expiry  of  his  sentence,  a  strong,  bad-looking,  dangerous 
fellow,  Avhom  we  regarded  as  the  worst  man  in  the  place. 
After  a  few  months  he  escaped,  and  after  being  in  hiding 
among  his  friends  for  a  short  time,  began  to  work,  and  has 
remained  an  industrious,  self-supporting  member  of  .society 
ever  since,  and  that  after  having  been  for  years  regarded  as 
a  most  dangerous  criminal  lunatic.  "No  doubt,  having  first 
to  secure  liis  safety  from  recapture,  and  then  to  earn  liis  own 
living,  and  being  away  from  those  whom  he  would  consider 
his  natural  enemies,  his  mind  would  be  distracted  from  his 
delusion,  and  it  would  cease  to  have  its  former  power  over 
him  to  influence  his  conduct. 

Pleasant  Delusions. — In  some  few  cases  delusions  of  unseen 
agency  are  pleasant  to  the  patient,  or  at  all  events  are  not 
complained  of.  Some  of  the  sexual  cases  are  of  tliis  character. 
Such  was  the  case  in  the  man  D.  S.,  Avho  wrote  me  tliis  letter  : — 

"  Record  of  Miracles. — The  Eeverend came  to  see 

me,  and  his  countenance  changed  to  that  of  my  deceased  uncle 

.     My  length  while  in  bed  was  increased  to  about 

seven  feet,  and  then  made  normal.  When  in  bed  a  very  pretty 
coloured  landscape,  including  cottage  and  woman  at  her  washing 
tub,  appeared  on  the  wall.  The  picture  could  not  have  been  pro- 
duced by  the  aid  of  the  camera.     P.  Smith,  casting  a  wry  look  at 


264  STATES    OF   FIXED   AXD   LIMTTED   DELUSION. 

me,  jumped  from  the  floor  to  a  heiglit  of  a  foot,  tlien  passed 
through  a  framed  picture  without  injury  thereto,  and  through  a 
sohd  14-inch  stone  "wall,  then  came  through  the  water-closet  door 
to  meet  me.  "While  peering  in  at  the  laundry  Trindows  a 
number  of  the  girls'  clothes  flew  off  them  while  at  their  washing 
tubs,  and  after  about  half  a  minute's- nakedness  their  clothes 
came  back  to  them,  and  they  were  properly  fastened  without 
their  aid.  'Neax  Myreside  Cottage,  James  S.,  astride  a  thin 
wire  fence,  was  seen  speeding  along  for  about  100  yards,  the 
wooden  posts  forming  no  impediment  to  his  '  wiremanship,'  " 
&c. 

I  have  under  my  care  at  present  a  gentleman,  D.  T.,  who 
beheves  he  is  under  the  power  of  "  an  automaton,"  who  con- 
trols him,  makes  him  scream  out,  talk  nonsense,  break  dishes, 
&c.  He  is  a  quiet  and  most  courteous  gentleman,  who,  after 
having  done  one  of  those  things,  will  reply,  if  asked  why  he 
behaved  so,  in  a  peculiarly  measured  calm  maimer — "The 
automaton  made  me  do  it.  I  did  not  wish  to  do  anything  of 
the  sort."  He  will  say  sometimes,  still  most  calmly,  "  WiU 
you  write  to  the  commissioners  to  remove  the  automaton  ? 
I  beg  to  renew  my  request  of  the  14th  July." 

Monomania  of  Stispicion. — The  third  great  class  of  delusional 
cases  are  those  of  suspicion.  Along  with  the  second  variety  it 
constitutes  the  "monomania  of  persecution"  of  some  authors. 
This  kind  of  delusional  condition  is  essentially  the  same  as  the 
last,  only  it  is  not  so  great  a  departure  from  soundness  of  mind. 
Patients  who  labour  under  tliis  form  of  mental  disease  do  not 
attribute  their  annoyances  to  unnatural,  unseen,  or  impossible 
means,  but  to  the  malevolence  of  real  persons  who  plot  against 
them,  have  evil  designs  on  them,  poison  their  food,  annoy  them, 
persecute  them,  prove  unfaithful  to  their  marriage  vows,  &c. 
We  all  know  that  the  natural  development  of  suspicion  is  very 
various  in  diflerent  people.  Many  people  are  of  a  suspicious 
temperament  from  the  beginning,  others  are  made  suspicious 
by  real  experiences  in  Kf  e  or  by  ill-health.  We  know  that  the 
weak  are  always  suspicious  tliroughout  the  whole  of  the  animal 


STATES   OF   FIXED  AND   LIMITED   DELUSION.  265 

kingdom.  It  is  the  same  with  the  human  brain — an  element 
of  morbid  suspicion  exists  at  the  beginning  of  nearly  all  cases 
of  melancholia.  I^othing  is  more  common  than  for  such 
persons  to  imagine  that  people  are  looking  at  them,  watching 
them,  and  following  them  about.  I  look  on  this  as  mental 
evidence  of  an  ill-nourished  or  anaemic  brain.  But  in  the 
class  of  persons  of  whom  I  am  to  speak,  it  is  a  chronic  mani- 
festation of  a  disordered  brain.  As  we  shall  see  when  I  come 
to  talk  of  phtliisical  insanity,  morbid  suspicion  is  the  most 
constant  sign  of  the  brain  malnutrition  that  goes  with  a  com- 
bination of  tuberculosis  and  insanity. 

"Joe  the  Tinsmith"  working  off  a  Delusion. — D.  T.  A.  is 
full  of  suspicions,  thinking  that  every  one  about  annoys  him 
on  purpose.  If  another  patient  coughs,  it  is  to  annoy  liim ; 
if  one  spits,  it  is  to  insult  him ;  if  one  sings,  the  words  refer 
to  him.  His  career  is  instructive.  He  was  a  soldier,  and  lived 
hard,  had  an  attack  of  acute  mania,  and  when  the  exaltation 
and  excitement  passed  off,  he  was  left  in  his  present  condition, 
and  has  remained  so  for  twenty-four  years.  For  the  first 
thirteen  years  he  was  regarded  as  a  dangerous  man,  and  it  was 
feared  to  put  any  sort  of  tool  or  instrument  into  his  hand,  for 
he  was  the  hero  of  many  fights — in  fact,  fought  or  wanted  to 
fight  someone  every  day.  But  as  he  was  a  tinsmith  originally, 
and  I  found  him  one  day  in  a  better  humour  than  usual,  I  sent 
him  to  the  tinsmith  shop  of  the  Asylum,  not  without  fears  that 
he  might  murder  some  one.  He  had  just  before  written  this 
letter : — "  I  write  to  you  to  let  you  know  that  I  am  much 
abused  here  by  villains.  I  will  be  clear  of  the  band  of  villains 
they  have  upon  me.  Be  so  good  as  come  before  they  kill  me. 
I  am  not  able  to  stand  death  here.  They  have  poisoned  me 
many  a  time.  I  will  not  stand  the  bloody  abuse  that  they  are 
giving  me.  A  fellow  they  call  Hamilton  (a  fellow-patient 
who  talked  to  himself)  is  abusing  me  most  awfuUy,"  &c. 
With  much  tobacco  and  a  httle  beer,  of  which  he  was  very 
fond,  and  many  promises  that  all  the  "viUainy"  would  be 
ended  if  he  would  work  well  and  not  fight,  we  set  him  to 


266  STATES   OF   FIXED   AND   LIMITED   DELUSION. 

work.  He  took  to  it  at  once,  worked  as  if  liis  life  depended 
on  it,  hammered  away  at  tin  and  copper  plates,  making 
them  into  utensils,  and  evidently  found  much  satisfaction  in 
the  outlet  that  unhmited  hammering  and  much  noise  gave  him 
for  his  muscular  energy  and  irritated  feehngs.  He  clearly 
treated  the  tin  plates  as  if  they  were  the  "villains"  that  had 
been  annoying  him.  The  great  difficulty  was  to  provide  him 
work  enough,  he  got  through  it  so  quickly.  From  that  day 
to  tliis,  now  fourteen  years,  "Joe  the  tinsmith"  has  been  one 
of  the  most  useful  members  of  our  community.  If  he  has  a 
fight,  it  is  usually  on  Sunday.  He  still  has  the  delusions  of 
suspicion,  but  they  are  not  all-powerful  in  his  mind  as  they 
were,  and  his  countenance  is  less  expressive  of  fierce  passion. 
He  has  got  to  believe  now  that  he  has  some  friends,  and  it 
molhfies  him.  He  died  last  year  of  cancer  in  the  stomach, 
which  had  caused  many  small  secondary  deposits  in  the  brain. 
But  apart  from  tliis  there  was  marked  disease  in  the  brain 
cortex,  with  hypertrophy  of  the  spider  cells  and  pigmentary 
and  granular  degenerations  of  the  nerve  cells. 

Patients  in  this  condition  of  morbid  suspicion  often  attach 
delusional  importance  to  simple  acts,  every  movement  of 
persons  near  them  having  to  them  a  liidden  meaning.  I  had  a 
clergyman  once,  D.  T.  B.,  under  my  care,  who  fancied  that  a 
conspiracy  had  been  got  up  against  liim  to  put  liim  out  of 
every  curacy  he  had  held,  and  to  prevent  liim  getting  a  Uving, 
that  the  bishop  had  been  concerned  in  this,  and  of  course 
magistrates  and  authorities  had  refused  him  redress.  Here  is 
part  of  a  letter  of  his  : — "  My  dear  Dr  Clouston,  I  have  oftener 
than  once  heard  of  your  welfare,  which  I  hope  will  go  on 
prosperously,  so  long  as  you  are  the  true  and  faithful  servant 
of  God,  though  no  further,  as  I  told  you.  My  state  of  outrage 
and  wrong  you  know  luell  or  better  than  I  do,  for  all  to  me  is 
a  complete  mystery  beyond  tohat  I  do  really  know  and  have 
been  compelled  to  feel.  In  places  of  tliis  kind  there  is  so  much 
'  pantomime,'  so  I  pay  no  attention  to  such  nonsense.  I  have 
received  no  redress  or  improvement  whatever  ! !     What  part 


STATES   OF   FIXED   AND   LIMITED   DELUSION.  267 

you  have  taken  in  the  wrong  I  am  suffering  you  knoio.  There 
are  and  have  been  several  nice  vacancies,  one  of  which  will 
suit  me,  though  any  part  of  England,  so  as  to  be  far  off 
the  atmosphere  of  asylums  will  suit  me.  I  am  in  constant 
expectation  of  'freedom,^  'compensation,''  and  a  'benefice^ 
of  my  own.  I  have  merit  and  purity  enough  for  a  bishop," — 
and  so  on  for  many  pages  of  complaint  and  morbid  suspicion. 
By  the  way,  you  will  notice  that  he  underHnes  much  of  his 
letter.  The  late  Sir  Robert  Christison  once  said  to  me  that 
he  could  usually  tell  a  man  who  laboured  under  insane  delu- 
sions by  the  way  he  unnecessarily  underlined  his  letters. 

Insane  Jealousy. — The  most  painful  of  all  the  cases  of  delu- 
sions of  suspicion  are  those  where  'a  husband  becomes  insanely 
jealous  of  his  wife,  or  the  wife  of  her  husband,  and  suspicious 
of  conjugal  fidelity  without  reason.  After  the  fuU  develop- 
ment of  such  a  case  it  is  easy  to  see  that  such  suspicions  are 
insane,  by  the  exaggerated  way  they  are  put,  and  by  the 
utter  want  of  evidence ;  but  at  the  beginning  they  are  most 
difficult  and  unpleasant.  I  have  now  a  lady  in  the  Asylum, 
D.  T.  C,  quiet  in  manner,  ladylike,  and  almost  rational,  who 
showed  her  insanity  first  by  going  to  her  clergyman  and 
making  a  confidential  report  to  him  that  her  husband  had 
given  her  syphihs,  and  he  was  accordingly  at  once  summoned 
for  ecclesiastical  censure  by  the  kirk-session  of  his  church. 
Being  a  sensitive,  nervous  man,  this  had  an  extraordinary 
effect  on  him.  Prom  being  fond  of  his  wife  he  suddenly 
conceived  a  hatred  of  her,  believing  that  it  was  a  deliberate 
plot  to  ruin  him.  Though  other  symptoms  of  insanity  de- 
veloped themselves  in  her,  he  never  to  his  dying  day  could 
be  made  to  believe  that  the  syphilis  delusion  was  any 
symptom  of  insanity  on  her  part,  but  looked  on  it  as  simply 
wickedness.  In  her  case  the  nature  of  her  delusion  seemed  to 
be  determined  by  the  fact  that  she  had  a  chronic  uterine 
tumour,  the  uneasy  sensations  connected  with  which  seemed 
to  have  suggested  it.  I  was  once  sent  for  in  great  haste,  as  a 
gentleman,  D.  T.  D.,  was  said  to  be  killing  his  wife.     I  found  a 


268  STATES   OF  FIXED  AND   LIMITED  DELUSION. 

most  respectable  man,  of  first-rate  business  capacity,  who  had 
made  a  large  fortune,  and  was  still  doing  business,  and  who 
was  reputed  by  the  world  at  large  to  be  perfectly  sane,  making 
the  most  outrageous  allegations  about  his  wife,  and  saying 
she  had  been  unfaithful  to  him,  I  soon  found  that  those 
accusations  were  of  necessity  insane  delusions.  He  had  seen 
her  wink  to  scavengers  as  she  passed  them.  He  had  met  her 
just  parted  from  a  labouring  man,  with  whom  she  had 
had  connexion  under  a  wall,  &c.  I  have  now  in  the  Asylum 
two  quiet  rational-looking  men,  whose  chief  delusion  is  that 
their  wives,  both  women  of  undoubted  good  character,  have 
been  unfaithful  to  them.  Keep  them  off  that  and  they  are 
rational.  On  that  subject  they  are  utterly  delusional  and 
insane.  They,  like  most  such  cases,  are  incurable.  The  true 
physiological  psychology  of  the  married  hfe  has  yet  to  be 
written.  The  unworthy  travesty  of  it  wMch  Tolstoi  presents 
in  the  Kreutzer  Sonata  is  a  brute,  not  a  human  psychology. 

As  an  example  of  a  perverted  sensation  or  a  local  pain 
causing  a  delusion,  I  had  once  a  gentleman  patient,  D.  T,  E., 
with  disease  of  the  rectum,  who  maintained  that  people  came 
at  night  and  committed  sodomy. 

It  is  not  uncommon  to  find  women  of  middle  life  with  the 
combined  delusions  that  certain  men  want  to  marry  them,  but 
that  other  people  are  preventing  this.  Clergymen  are  the 
most  frequent  objects  of  this  very  undesirable  fancy.  I  have 
met  with  at  least  a  dozen  cases  in  all  ranks  of  life  of  this 
kind.  The  subjects  of  it  are  usually  not  marriageable  nor 
attractive-looking  persons.  I  will  show  you  a  one-legged 
dressmaker  of  40,  D.  T,  F.,  with  certainly  no  personal  charms, 
who  went  to  her  clergyman  and  asked  him  to  "proclaim"  her 

and  Mr in  church.     On  inquiry,  he  found  the  gentleman 

to  be  proclaimed  had  never  spoken  to  her.  He  sat  opposite 
her  in  church,  and  she  said  he  looked  at  her  in  such  a 
significant  way  that  she  knew  he  wanted  their  banns 
proclaimed.  D.  T.  F.  said  it  was  all  owing  to  a  scheming 
neighbour  that  she  was  not  married  to  Mr  . 


STATES   OF  FIXED   AND   LIMITED   DELUSION.  269 

A  morbid  feeling  of  fear  is  often  associated  with  that  of 
suspicion,  especially  in  the  cases  that  have  arisen  out  of  melan- 
cholia. I  have  a  patient  who  is  afraid,  if  I  take  out  my  hand- 
kerchief, that  it  means  something  evil  towards  herself,  who  is 
constantly  saying — "  IsTow,  doctor,  I  know  you  are  going  to  do 
something  to  me ;  what  is  it  to  be  ? " 

It  is  common  for  patients  with  monomania  of  suspicion  to 
conceal  their  delusions,  except  to  intimate  friends  or  near  rela- 
tions, for  a  long  time,  even  for  years,  and  when  asked  about 
them  to  deny  that  they  believe  them.  "We  once  had  a  gentle- 
man in  Morningside,  D.  T.  G.,  who  was  full  of  morbid 
suspicions,  believing  that  some  of  the  people  about  him  were 
other  persons  altogether,  and  that  he  was  at  times  in  danger 
of  his  life  from  poison.  Yet  for  many  years  he  never  told 
those  things  to  any  person  but  one  fellow-patient.  Unlike  the 
majority  of  such  cases,  he  was  to  most  persons  a  pleasant  man  ; 
his  social  instincts  were  strong,  he  was  fairly  happy,  going  all 
about  the  country  on  fishing  excursions,  and  enjoying  a  joke 
and  good  story  immensely.  Before  his  death,  when  his  brain 
disease  had  advanced,  he  was  not  so  reticent  about  his 
delusions.  I  have  now  two  patients,  D.  T.  H.  and  D.  T.  L, 
who  on  their  first  admissions  I  had  to  discharge  because  they 
denied  their  delusions  so  strenuously.  In  fact,  D.  T.  H.  was 
twice  discharged  for  that  reason.  Yet  they  both  laboured 
under  insane  suspicions,  that  the  people  in  their  houses  and 
the  streets  annoyed  them,  and  wanted  to  kill  them.  Wlien- 
ever  D.  T.  H.  got  a  glass  of  whisky  these  delusions  at  once 
came  out.  On  one  occasion  the  second  medical  certificate  for 
his  admission  could  not  be  got,  and  he  was  tried  before  the 
Sherifi"  for  threatening  language.  I  had  to  say  that  I  beheved 
him  to  be  insane,  but  that  I  had  no  proofs  of  it  from  himself. 
That  was  deemed  sufficient,  and  he  was  committed  to  the 
Asylum.  I  have  another  patient  who  has  been  four  times  in 
an  asylum,  and.  while  there  has  never  uttered  one  insane 
suspicion,  though  full  of  such  about  his  wife,  and  really 
dangerous  to  her. 


270  STATES   OF   FIXED   AND   LIMITED   DELUSION. 

Insane  Silence. — There  are  cases  of  monomania  not  to  be 
classified  under  those  three  headings.  I  have,  for  instance,  a 
man  in  the  Asylum,  D.  K.  T.,  who  for  twenty-five  years  has 
never  spoken  a  word,  but  who  I  may  say  in  all  other  respects 
behaves  sanely,  showing  no  symptoms  of  morbid  pride  or 
suspicion.  He  is  about  the  best  joiner  we  have.  "We  know 
he  has  a  delusion  which  prevents  liim  speaking,  but  what  it  is 
we  can't  find  out.  If  he  wants  instructions  about  his  work 
he  writes,  but  nothing  will  induce  him  to  write  why  he  won't 
speak.  He  has  never  been  heard  to  make  any  laryngeal  noise 
except  once,  when  a  fellow-patient  scattered  some  tacks 
round  his  bed,  and  on  stepping,  on  "the  business  end"  of  one 
of  those  he  cried  "  Oh  !  " 

There  are  certain  patients,  too,  who  simply  express  delusions 
as  to  the  identity  of  those  about  them,  without  any  suspicious, 
fearful,  or  persecuted  feeling  (see  D.  0.  A.'s  letter,  p.  256). 
There  is  indeed  a  great  variety  in  the  symptoms  of  those  who 
labour  under  delusional  insanity. 

Proportion  of  Cases  of  Monomania. — At  the  close  of  the 
year  1881  there  were  822  patients  of  all  classes  in  the  Eoyal 
Edinburgh  Asylum,  and  of  these  87  were  cases  of  delusional 
insanity,  viz.,  35  of  grandeur,  14  of  unseen  agency,  and  38  of 
suspicion.  Of  the  -87,  48  were  men  out  of  the  421  male 
patients,  so  that  the  proportion  in  the  two  sexes  did  not 
drffer  much.  There  were  more  cases  of  monomania  of  pride 
and  grandeur  among  the  women  than  among  the  men — 20  to 
15,  while  of  suspicion  there  were  25  among  the  men  to  only 
13  among  the  women.  I  found  one  marked  phenomenon  in 
the  natural  history  of  delusional  insanity.  Out  of  120  patients 
of'  the  Mgher  classes  socially,  all  with  educated  brains,  and 
many  of  them  of  old  famih'es,  there  were  23  cases  of  mono- 
mania, or  about  one-fifth  of  the  whole,  while  among  the 
554  pauper  patients  there  were  only  44  cases  of  this  variety 
of  mental  disease,  or  only  one-twelfth  of  the  whole.  The  158 
private  patients  of  loAver  social  class  were  intermediate,  and 
had  20  cases  of  monomania,  or  over  one-seventh.     It  would 


STATES   OF   FIXED   AND   LIMITED    DELUSION.'  271 

seem,  tlieref ore,  that  delusional  insanity  is  most  apt  to  occur 
in  brains  of  the  highest  education. 

Diagnosis  of  Monomania. — I  had  a  woman  sent  into  the 
Asylum  lately,  who  told  me  she  was  the  mother  of  God.  We 
had  no  history  of  the  case  at  all.  There  was  no  general  exal- 
tation, no  excitement,  and  no  depression  apparent.  Was  not 
that  a  case  of  delusional  insanity  ?  'Sot  in  a  correct  use  of  the 
term,  for  the  woman  gradually  passed  into  an  attack  of  simple 
mania,  ceasing  to  express  this  particular  delusion  after  a  few 
days.  Therefore  you  must  always  take  into  account  the  fixed- 
ness of"  the  delusion  or  the  delusional  state,  and  the  time  the 
patient  has  suffered  from  it.  Many  maniacal  and  melanchohc 
patients  begin  by  expressing  a  single  delusion,  or  exhibiting  a 
single  delusional  state,  as  the  commencement  of  their  general 
disease.  I  have  met  with  plenty  of  cases,  too,  where,  from  the 
very  sub-acuteness  of  the  mania  or  the  melancholia,  the  symp- 
toms of  general  exaltation  or  depression  were  not  very  evident, 
and  a  delusion  stood  out  as  apparently  the  disease,  and  yet 
the  patient  soon  recovered.  And  as  patients  are  recovering 
from  mania  and  melancholia  they  often  exhibit  delusional 
conditions  iox  a  long  time  after  the  general  exaltation  or 
depression  has  passed  off.  I  had  a  patient  who  had  an  attack 
of  acute  mania  lasting  for  three  months,  and  after  that,  though 
quiet,  industrious,  and  rational  on  most  subjects,  he  believed 
his  food  was  poisoned  for  twelve  months.  He  then  gradually 
ceased  to  believe  his  food  was  being  poisoned,  but  he  believed 
that  it  had  been  poisoned  before  for  twelve  months  longer. 
I  classify  sucha  case  as  one  of  acute  mania,  not  of  monomania 
of  suspicion.  A  recovered  patient's  behef  in  the  reahty  of 
his  former  delusions  is  not  at  all  uncommon.  A  man  says : 
"No  one  annoys  me  now,  but  I  was  subjected  to  persecution 
at  home,  and  when  first  t  came  into  the  Asylum."  I  should 
not  keep  a  man  in  an  asylum,  or  count  him  a  monomaniac,  or 
even  necessarily  reckon  him  as  legally  insane,  merely  because 
he  beheved  in  the  reality  of  liis  former  delusions,  if  he  had 
ceased  to  believe  in  their  present  existence,  any  more  than  I 


272  STATES   OF   FIXED   AXD   LIMITED   DELUSION. 

should  count  a  man  insane  wlio  could  not  get  rid  of  the 
impression  tliat  the  events  of  a  dream  had  really  taken  place. 
The  two  chief  things  to  be  kept  in  mmd  in  the  diagnosis  of 
monomania  are : — 1st,  not  to  call  any  disease  by  that  name 
that  has  not  existed  unaltered  for  at  least  twelve  months ;  and 
2nd,  when  there  exists  along  with  the  delusional  condition  any 
general  brain  exaltation  or  excitement,  or  any  general  depres- 
sion, not  to  call  it  by  that  name  till  those  have  passed  off. 

Origin  of  Monomania. — The  question  has  been  keenly  dis- 
cussed whether  morbid  emotion  or  faulty  cognition  initiates 
monomania.  It  is  one  impossible  of  determination.  I  beheve 
the  affective  state  is  always  disturbed  in  the  disease,  and  com- 
monly it  is  more  disturbed  at  the  beginning.  I  do  not  beheve. 
the  false  beliefs  always  arise  out  o/the  disturbed  emotions,  how- 
ever. Looked  at  from  the  brain  point  of  view,  it  arises  in  at 
least  f  aur  different  ways  in  different  cases.  1st,  It  is  a  gradual 
evolution  out  of  a  natural  disposition,  a  proud  man  becoming 
insanely  and  delusionally  proud,  a  naturally  suspicious  man 
passing  the  sane  borderland  with  his  suspicions.  From  going 
over  our  cases  I  find  about  one-fourth  of  them  arose  in  this 
way.  It  is  the  most  common  origin  of  the  disease.  There  is 
usually  an  hereditary  predisposition  to  insanity  in  those  patients. 
The  disposition  may  in  fact  be  regarded  as  one  effect  of  the 
nervous  diathesis  out  of  wliich  the  mental  disease  springs. 
2nd,  It  remains  as  a  permanent  brain  result  and  damage  after 
attacks  of  mania  and  melanchoha,  especially  the  former,  from 
wliich  the  patients  recover  up  to  a  certain  point  but  no  further. 
This  is  the  origin  of  about  one-sixth  of  the  cases.  3rd,  It 
arises  from  alcohoHc  and  syphihtic  poisoning  of  the  brain  and 
body,  from  traumatic  injuries  of  the  brain,  or  sunstroke,  or 
from  gross  lesions,  such  as  embohc  softenings.  This  seems  to 
me  to  be  its  origin  in  about  one-fifth  of  the  cases.  Such  have 
usually  the  delusional  insanity  of  suspicion  or  unseen  agency. 
They  are  the  most  dangerous  class  of  monomaniacs  on  the 
whole.  4th,  Most  of  the  remainder,  comprising  over  one- 
third  of  the  cases,  seemed  to  me  to  arise  either  out  of  perverted 


STATES   OF  FIXED   AND   LIMITED   DELUSION.  273 

organic  sensations  caused  by  constitutional  diseases  charac- 
terised by  lack  of  trophic  power  and  brain  anaemia,  notably 
tuberculosis,  or  out  of  perverted  sensations  from  local  diseases 
misinterpreted  by  the  brain,  as  in  the  woman  with  cancer  of 
stomach.  Any  man  with  an  anaemic  ill-nourished  brain  is  apt 
to  be  morbidly  suspicious. 

Legal  Importance  of  Insane  Delusions. — Delusions  are  often 
of  small  clinical  import,  but  are  always  of  the  highest  value  as 
a  test  of  insanity  from  the  lawyer's  point  of  view.  Therefore 
I  advise  you  to  bring  them  in  always,  if  they  exist,  in  signing 
certificates  of  insanity,  in  medico-legal  documents,  and  in 
giving  evidence  before  courts  of  justice.  But  you  must 
remember  there  are  harmless  and  dangerous  delusions ;  and  if 
a  delusion  is  obviously  harmless,  and  does  not  bulk  largely  in 
the  patient's  hfe  or  greatly  affect  Ms  conduct,  the  law  scarcely 
recognises  it  as  unsoundness  of  mind  at  all.  It  is  quite 
impossible  to  distinguish  scientifically  between  some  vain  or 
proud  men,  who  dress  and  behave  in  an  absurd  manner,  but 
do  nothing  needing  interference  with  their  hberty,  and  the 
man  who  thinks  himself  the  son  of  George  the  Fourth,  claims 
property  that  does  not  belong  to  him,  and  is  therefore  shut  up 
in  an  asylum.  There  are  plenty  of  persons  doing  their  work 
in  the  world  well,  and  yet  they  labour  under  monomania  of 
pride  or  suspicion  in  a  mild  form.  The  now  famous  case  of 
J\lr  Wyld,  who  held  an  important  Government  office,  and  did 
liis  work  well  all  his  hfe,  and  yet  had  laboured  under  the 
delusion  of  grandeur,  that  he  was  a  son  of  George  the  Fourth, 
and  left  all  his  money  to  the  town  of  Brighton  because  that 
monarch  had  been  fond  of  that  place,  is  one  in  point.  He 
was  held  to  be  sane  in  everything  he  did  but  his  will-making. 
I  am  constantly  consulted  by  their  friends  about  the  insane 
delusions  of  persons  who  do  not  show  them  to  anybody  but 
their  near  relations,  and  continue  to  do  their  work  and  occupy 
responsible  positions.  I  now.  know  in  Scotland  lawyers, 
doctors,  clergymen,  business  men,  and  workmen,  who  labour 
under  undoubted  delusional  insanity,  and  yet  do  their  work 

S 


274  STATES   OF  FIXED  AND   LIMITED   DELUSION. 

about  as  well  as  if  they  had  heen  quite  sane,  though  they  are 
not  such  pleasant  people  as  they  would  have  heen  if  really 
sound  in  mind,  especially  to  their  relatives. 

Treatment  of  Delusional  Insanity. — At  the  beginning,  when 
there  is  a  chance  of  the  delusions  not  being  quite  fixed,  there 
are  two  indications  for  treatment.  The  first  is  change  of 
scene,  circumstances,  company,  and  occujDation,  which  can 
best  be  got  by  travelling  about.  The  mind  may  be  sometimes 
diverted  from  morbid  tendencies  in  that  way.  And,  while 
this  is  being  done,  the  second  indication  should  be  carried  out, 
which  is  to  correct  and  cure  bodily  disorders,  to  treat  con- 
stitutional diseases  Kke  tuberculosis  and  syphihs  and  anaemia 
by  sliitable  means,  and  to  remove  every  bodily  cause  of  con- 
volutional  disturbance,  to  withdraw  objects  of  suspicion,  and 
to  bring  up  to  the  highest  possible  mark  the  nervous  and 
bodily  tone.  By  this  means  there  is  no  doubt  that  some  cases, 
especially  those  characterised  by  morbid  suspicion,  can  be 
cured,  even  after  they  have  existed  for  years.  I  have  even 
seen  a  marked  case  of  monomania  of  grandeur  get  better.  A 
man  who  for  more  than  a  year  fancied  himself  the  Duke  of 
Kilmarnock  got  quite  well,  through  improvement  in  his  bodily 
health  and  working  in  the  Asylum  garden.  In  a  few  cases 
with  hallucinations  of  hearing,  the  continued  current  through 
the  brain  has  seemed  to  do  good.  But  for  the  confirmed 
monomaniacs  of  all  sorts,  who  will  insist  on  carrying  out  their 
ideas,  an  asylum  is  the  only  possible  place  of  care.  Dr  Charles 
H.  Skae  cured  a  case  of  monomania  of  suspicion,  caused 
through  an  injury  to  his  head,  by  trepliining. 

Prognosis. — The  prospect  of  recovery  is  certainly  very  bad 
in  cases  of  delusional  insanity  that  have  lasted  for  over  a  year, 
but  one  is  surprised  sometimes  by  occasional  recoveries  after 
many  years.  There  is  a  tendency  to  mental  enfeeblement  as 
time  goes  on.  Some  cases  end  in  complete  dementia  after 
a  few  years,  and  in  most  the  intensity  of  the  conviction  of 
the  delusion,  and  the  aggressiveness  with  Avhich  ib  is  put  for- 
ward, tend  to  diminish  as  time  goes  on.      Many  monomaniacs 


STATES   OF  FIXED   AND   LIMITED   DELUSION.  275 

live  long,  but  the  cases  of  morbid  suspicion  mostly  die  of 
phthisis. 

Propliylaxis. — I  think  something  can  be  done,  in  those  who 
are  predisposed  towards  delusional  insanity  by  their  nervous 
diathesis  and  hereditary  predisposition  to  the  neuroses  or  to 
consumption,  or  to  both,  towards  counteracting  the  morbid 
disposition.  "While  the  reasoning  power  still  holds  its  sway  it 
may  be  used  in  deliberate  attempts  to  reason  a  man  out  of  his 
morbid  tendencies.  I  tliink  I  have  seen  a  man  in  this  way, 
and  by  not  allowing  himself  to  dwell  on  morbid  thoughts  and 
feehngs,  keep  in  check  a  morbid  disposition.  Good  principles 
and  good  habits  of  life  help  greatly  in  the  same  direction. 
Occupation  may  be  helpful,  too,  in  counteracting  it.  I  have 
often  seen  monomania  of  suspicion  arise  out  of  a  suspicious 
reserved  temperament  in  young  men  through  the  thoughtless 
and  cruel  small  persecutions  and  annoyances  of  fellow-clerks 
and  fellow-workmen.  It  is  from  this  exciting  cause  chiefly 
that  hunchbacks  and  deformed  persons  are  so  often  suspicious, 
irritable,  and  misanthropic,  the  predisposing  cause,  no  doubt, 
being  their  developmental  neurotic  weakness.  Human  nature 
is  not  tender  or  considerate  towards  such  weaknesses.  I 
have  seen  a  proud  disposition  become  a  monomania  of  pride 
through  the  injudicious  pamperings  and  foohsh  adulation  of 
female  relations,  and  the  encouragement  of  such  a  person  in 
occupations  and  schemes  beyond  his  capacity  or  means.  IS^o 
doubt  temperate  and  systematic  habits  in  all  things  are  very 
prophylatic  for  the  kind  of  brains  I  am  now  describing.  I 
think  I  have  seen  cheerful  family  life  cure  a  commencing 
delusion  of  suspicion.  Association  with  their  fellow-men  is 
good  for  all  persons  predisposed  in  this  way,  provided  they 
can  get  suitable  company  to  associate  with.  To  be  suitable, 
it  needs  often  to  be  opposite  and  complemental.  In  all 
persons  predisposed  to  delusional  insanity  the  social  instincts 
are  apt  to  be  rudimentary  and  need  development.  In  some 
of  those  who  show  their  morbid  tendencies  at.  an  early  period 
of  life,  they  can  be  prevented,  the  brain  being  still  plastic. 


276  STATES   OF   FIXED   AND   LIMITED   DELUSION. 

PAEAlfOIA. 

There  has  been  of  late  years  in  Germany  a  decided 
tendency  to  discard  the  conditions  of  fixed  and  Kmited  delu- 
sion, such  as  I  have  described,  as  a  distinct  form  of  mental 
disease,  and  to  substitute  for  monomania  the  term  paranoia, 
not  as  covering  the  same  ground,  but  as  including  most  cases 
of  monomania,  and  some  others  that  would  have  come  under 
impulsive  insanity,  or  under  mild  dementia,  or  even  under 
simple  mania.  It  is  exceedingly  difficult  to  define  paranoia  as 
the  term  is  used  in  Germany,  and  now  largely  also  in  America. 
As  yet  it  is  clear  that  different  authors  understand  by  it 
different  things,  but  taking  the  sense  of  the  majority  of  them, 
I  think  the  following  may  be  accepted  as  a  short  description 
of  the  condition.  It  always  occurs  in  persons  in  whose 
brains  there  is  the  potentiaHty  of  mental  or  nervous  disease 
through  hereditary  predisposition  to  the  psychoses  or  the 
neuroses.  It  is,  in  fact,  a  strongly  hereditary  insanity.  It 
evolves  slowly  without  an  acute  first  stage.  It  consists,  in 
fact,  of  a  slowly  developed  change  from  the  normal  mental 
state  of  the  individual,  and  most  commonly  in  the  direction 
of  elevated  ideas  and  exaggerated  self-importance.  Sometimes 
the  change  is  towards  morbid  suspicion  and  sensitiveness,  this 
often  going  with  the  elevated  ideas.  Sometimes  the  sexual 
instincts  are  changed  or  perverted,  constituting  the  "sexual 
paranoiac"  who  has  attracted  such  an  amount  of  morbid 
attention  in  Germany.  The  conduct  is  always  aflTected,  but 
not  necessarily  at  first  taking  the  form  of  actually  insane 
action.  Queernesses,  oddities,  impracticabihty,  insensibility 
to  the  motives  which  ordinarily  influence  humanity  — 
abnormal  mental  reaction,  in  fact.  The  reasoning  power 
cannot  correct  obviously  mistaken  conclusions,  and  cannot 
be  trusted  in  regard  to  any  subject.  The  hereditary  social 
instincts  and  the  gregariousness  which  seem  to  be  the  chief 
factor  of  the  sohdarity  of  human  society  are  weakened,  and 
gradually  become  perverted.     Hereditary  moraHty,  probably 


STATES  OF   FIXED   AND   LIMITED   DELUSION.  277 

the  strongest  ethical  force,  is  weak  in  its  power  over  conduct, 
or  assumes  perverted  and  diseased  shapes.  The  instincts, 
appetites,  and  propensities  are  disturbed  or  perverted.  The 
affective  nature  is  always  changed.  !N"o  paranoiac  loves  liis 
wife,  or  his  brethren,  or  his  friends  in  the  right  and  normal 
way.  His  afFectiveness  takes  strange  and  often  asocial  forms, 
so  that  instead  of  holding  together  and  upholding  the  family 
and  the  state,  it  is  disruptive  in  its  effects.  The  moral 
sanctions  and  the  affective  drawings  of  the  paranoiac  do  not 
tend  towards  social  cohesion,  but  destruction.  The  man  of 
the  "insane  diathesis,"  as  described  by  Maudsley,  is  a  para- 
noiac in  its  early  stage ;  later  on  he  develops  delusions,  but 
not  always  fixed  or  organised  delusions.  He  often  commits 
crime,  thinking  it  a  virtue,  as  Guiteau  did  when  he  murdered 
President  Garfield  who  had  done  him  no  harm  whatever. 
Still  later  the  paranoiac  often  sinks  into  mental  enfeeblement, 
not  of  the  complete  kind,  but  often  enough  he  lives  out  his 
life  without  thus  mentally  dying.  King  Louis  II.  of  Bavaria^ 
was  a  typical  case  of  paranoia,  all  the  symptoms  of  the  disease 
being  developed  in  exaggerated  forms  through  his  autocratic 
position  and  command  of  money,  and  brought  out  vividly 
through  the  "  fierce  light  that  beats  upon  a  throne."  In  him 
there  appeared  to  have  been  sexual  perversion  of  the  most 
abominable  description.  This  unsavoury  subject  and  all  that 
relates  to  the  pathological  manifestations  of  the  generative 
nisus  have  recently  been  very  fully — far  too  fully,  I  take  leave 
to  say — treated  by  Krafft-Ebing  and  Schrenck-Notzing  in 
Germany.  In  this  country  we  rarely  see  such  cases  as  are 
described  in  such  repulsive  detail  by  those  two  authors,  and  I 
think  it  is  better  we  should  not  look  too  closely  for  them. 
The  whole  subject  of  paranoia  is  allied  to  the  "  degeneracy  " 
and  the  "hysteria  "  which  Max  Nordau  so  vividly  describes 
as  influencing  our  present-day  ^  literature  and  art. 

^  See  Dr  Ireland's  study  of  him  in  his  delightful  series  of  Studies  in 
Psychology  and  History — "Through  the  Ivory  Gate." 
^  Degeneration,  by  Max  Nordau. 


LECTUEE   VII. 

STATES  OF  MENTAL  ENEEEBLEMENT  {DEMENTIA, 
AMENTIA,  PSYCHOPARESIS,  CONGENITAL  IM- 
BECILITY, IDIOCY). 

Physiological  weakness  of  mind  ;  Cliildhood  and  Dotage — AVeakness  of 
mind  in  ordinary  bodily  diseases  from  Starvation,  Exhaustion,  ex- 
treme mental  effort  and  tension,  or  emotional  shocks — Definition  of 
true  Dementia  ;  symptoms  negative — Enfeeblement  general,  but 
not  uniform,  of  all  the  faculties  and  mental  powers — Originating 
mental  power  first  and  most  markedly  aflfected — No  line  of  demar- 
cation between  Sane  and  Insane  weakness  of  mind.  Varieties — 
{a)  Secondary  {Terminal)  Dementia :  The  most  common,  important, 
•  and  characteristic  Dementia  of  all ;  The  natural  termination  of  all 
Insanities,  if  recovery  or  death  do  not  occur  ;  acute  Insanities  tend 
most  towards  it,  especially  acutely  maniacal  states — S.  Dementia. 
Pathologically  considered  weakened  trophic  and  functional  state 
of  a  delicate  structure  (originally  unstable),  commonly  following 
morbid  over-action — A  typical  case  ;  clinical  features  ;  heredity  ; 
acute  mania ;  non-recovery ;  changes  in  expression  of  face,  of 
tastes,  habits,  volition,  judgment ;  moral  faculties ;  affective 
nature  ;  memory  ;  silliness  ;  a  mental  death  before  the  rest  of  the 
body  dies — Re-education  of  brain  ;  limits  ;  bodily  health  often 
good  ;  long  life — (  Varieties)  Things  tending  to  Dementia  :  (1)  Occur- 
rence of  primary  attack  during  adolescence  ;  (2)  long  duration  of 
attack  ;  (3)  acuteness  ;  (4)  many  previous  attacks  ;  (5)  heredity 
very  strong.  If  1,  2,  and  5  are  all  present,  risk  very  great.  Treat- 
ment— Dementia  in  rare  cases  comes  on  gradually  without  acute 
insanity  or  other  known  exciting  cause.  Milder  forms  of  mental 
weakness,  mental  "twists,"  and  changes,  often  follow  attacks  of 
insanity  and  apparent  recovery — Temporary  states  resembling  De- 
mentia and  Stupor  that  are  recovered  from  after  acute  attacks  of 
mania — (&)  Primary  Dementia:  Congenital  Imbecility,  Idiocj^, 
Amentia,  Cretinism.  Ireland's  classification — Genetous  Idiocy, 
Eclampsic  I.,  Epileptic  I.,  Paralytic  I.,  Inflammatory  I.,  Traumatic 
I.,  Microcephalic   I.,    Hydrocephalic   I.,   Idiocy   by   Deprivation, 


STATES   OF   MENTAL   ENFEEBLEMENT.  279 

Cretinism — (c)  Senile  Dementia :  Kinship  of  this  to  Secondary- 
Dementia.  Special  Characteristics :  Irritability  ;  loss  of  memory  ; 
sometimes  follows  Senile  Mania  and  Senile  Melancholia— {d)  Organic 
Dementia:  Results  from  Softenings,  Apoplexies,  Tumours,  and  such 
gross  Brain  lesions — (c)  Alcoholic  Dementia:  The  judging  faculties, 
the  emotions,  the  volition,  but  especially  the  memory,  weakened 
by  continuous  alcoholic  poisoning. 

We  use  the  term  "  mental  enfeeblement,"  not  in  its  wide  and 
popular  sense,  meaning  any  mental  weakness  or  disease  what- 
ever, but  in  a  special  and  scientific  sense.  It  may  be  defined 
as  "  a  general  weakening  of  the  mental  power,  comprising 
usually  a  lack  of  reasoning  capacity,  a  diminution  of  feeling, 
a  lessened  volitional  and  inhibitory  power,  a  failure  of 
memory,  and  a  want  of  attention,  interest,  and  curiosity  in  a 
person  who  had  those  mental  qualities  and  has  lost  them,  or 
has  come  to  the  age  to  have  them  and  they  have  not  been 
developed."  There  are  two  great  physiological  periods  of 
mental  enfeeblement,  viz.,  in  childhood  and  old  age.  Consider 
the  condition  of  a  child  of  two  as  to  reasoning  power.  There 
are  many  words  indicating  a  lack  of  mental  power  that  have 
two  meanings,  a  pleasant  or  an  unpleasant  one,  according  as 
they  are  used  in  reference  to  a  child  whose  mindlessness  is 
physiological  or  to  a  man  in  whom  it  is  morbid.  What  more 
charming  than  "prattle,"  "  artlessness,"  "childishness," 
"  innocence,"  as  applied  to  a  child  ?  But,  said  of  a  man,  they 
mean  "chatter,"  "silliness,"  "lack  of  sense,"  or  "a  want." 
If  the  brain  development  is  arrested  before  birth  or  in  child- 
hood we  have  congenital  imbecility  and  idiocy — amentia. 
Dotage  must  be  reckoned  as  natural  at  the  end  of  life.  It 
is  not  actually  the  same  as  senile  dementia,  but  there  is  no 
scientific  diflerence.  Mental  enfeeblement,  both  in  judgment, 
feeling,  memory,  and  volition,  frequently  occurs  in  and  after 
bodily  diseases,  especially  after  fevers.  It  always  occurs  in 
the  process  of  death  by  starvation.  It  frequently  is  seen 
after  the  exhaustion  of  long  journeys,  great  exertions,  severe 
campaigns,  and  great  mental  tension,  strains,  or  efforts,  such 
as   business   crises,    sieges,    &c.     It   sometimes   occurs   after 


280  STATES  OF  MENTAL  ENFEEBLEMENT. 

sudden  or  great  emotional  shocks,  such  as  loss  of  children. 
iSTow,  in  all  these  cases  the  actual  psychological  condition 
may  be  the  very  same  as  in  patients  labouring  under  mental 
disease  proper,  or  technical  insanity.  Yet  we  do  not 
practically  reckon  them  in  that  category  except  they  are 
unusually  severe  or  very  lasting.  The  student  of  brain 
function  and  medical  psychology,  as  well  as  the  practical 
physician,  finds  a  study  and  comparison  of  those  conditions 
of  mental  enfeeblement  most  profitable. 

The  conditions  of  mental  enfeeblement  that  are  ordinarily 
reckoned  among  mental  diseases  may  exist  in  every  possible 
degree,  from  the  merest  dulling  of  the  keen  edge  of  certain 
mental  and  moral  faculties  up  to  complete  loss  of  intelhgence, 
feeling,  and  memory.  One  man  may  be  just  so  much  altered 
that  his  friends  say — "He  is  not  the  same  man  he  once 
was,"  and  another  may  not  be  able  to  comprehend  or  answer 
the  simplest  questions  or  to  recollect  his  own  name.  A  clever 
man  may  be  left  in  such  a  condition  that  in  his  shght  dementia 
he  is  more  intelligent  than  another  stupid  man.  A  man. may, 
while  he  is  not  energising  mentally,  seem  as  other  men  are,  or 
as  he  once  was,  but,  when  he  comes  to  think,  or  act,  or  work, 
it  is  seen  that  he  cannot  do  so  as  before.  In  most  cases 
all  the  mental  faculties  are  enfeebled  together,  either  equally, 
or  one  suffering  more  and  another  less.  In  a  few  cases  some 
mental  faculties  are  left  almost  intact,  while  others  are  almost 
destroyed.  I  have  a  patient  now  whose  brain  was  on^e  a 
very  energetic  and  subtle  one  and  his  memory  extraordinarily 
retentive,  who  talks  quite  rationally  on  all  kinds  of  subjects 
if  they  are  suggested  to  him  or  if  you  "  draw  him  out,"  and 
who  argues  most  correctly,  but  who  never  originates  anything, 
is  utterly  helpless  in  action,  and  who  ca.nnot  teU  you  the  day 
of  the  week  or  what  he  had  for  breakfast ;  this  condition 
being  the  result — a  common  one — of  many  years  of  alcoholic 
excess.  Tlie  originating  power  of  mind,  spontaneity  of 
thought  and  feehng,  active  vigour  of  Avill,  that  highest  quahty 
of  all,  are  always  diminished  or  lost  in  dementia.     I  know  a 


STATES   OF   MENTAL  ENFEEBLEMENT.  281 

man  who  when  well  always  impressed  those  with  whom 
he  came  in  contact  as  being  a  leader  of  men,  and  who  now., 
after  an  attack  of  mania,  has  lost  the  power  of  producing  that 
impression.  As  one  of  his  friends  said  to  me — "  I  was  always 
afraid  of  Mr  ^ — ■ — ,  and  never  could  be  familiar  with  him. 
Now  that's  gone."  Pathologically  and  psychologically  the 
mental  state  of  such  a  man  is  the  same  in  kind,  if  not  in  de- 
gree, as  the  absolute  dement  of  asylums.  Yet,  of  course,  the 
degree  makes  a  great  difference  from  a  legal  and  social  point 
of  view.  One  man's  mind  may  be  slightly  weakened  and  yet 
he  may  enjoy  his  personal  freedom,  and  another  man  who  is  a 
little  more  affected  has  to  be  deprived  of  this ;  but  there  is 
no  line  of  demarcation,  and  no  test  to  distinguish  between 
technical  sanity  and  technical  insanity  in  dementia. 

It  must  be  remembered  that  in  all  insanity  there  is  an 
element— often  a  strong  one — of  mental  enfeeblement  pure 
and  simple.  Most  cases  of  exaltation  have  enfeeblement  of 
judging  power  as  well  as  of  feeling.  Many  cases  of  melan- 
cholia are  enfeebled  as  well  as  depressed.  It  is  the  prevailing 
morbid  condition  that  determines  the  name  we  give  the 
disease. 

A  typical  case  of  complete  dementia  is  one  affected  as  this 
young  man,  E.  A.,  is.  As  he  came  into  the  room  his  walk  was 
hesitating,  almost  shuffling,  and  you  see  his  bodily  attitude  is 
one  of  diminished  muscular  and  nervous  vigour.  He  stoops, 
his  face  is  vacant  looking,  he  has  no  curiosity  as  to  where  he 
is  coming,  or  as  to  what  I  am  saying  about  him  ;  when  I  ask 
him  his  name  he  tells  it,  but  cannot  tell  the  day,  or  month,  or 
year.  In  asking  him  questions,  I  have  to  adopt  means,  by 
speaking  loud  and  sharply,  or  by  patting  his  arm,  to  rouse  his 
attention  to  listen  to  me.  His  mental  operations  are  slow  as 
well  as  weak,  for  it  takes  his  brain  long  apparently  to  take 
up  impressions  from  the  senses,  and  still  longer  to  evolve  the 
outward  process  of  speech  in  response,  his  mental  reaction- 
time  being,  in  fact,  very  much  prolonged.  When  I  ask  him, 
"  Where  were  you  born  1 "  he  says,  after  a  minute,  "  Oh  yes,  I 


282  STATES   OF   MEXTAL  ENFEEBLEMENT. 

think  so."  When  I  ask  liim  "Who  is  that?"  pointing  to  a 
student,  "That's  my  uncle  John."  "What  place  is  this  you 
are  hving  in?"  "I  don't  know."  "Did  you  ever  ask  any 
one  what  place  it  was?"  "Yes."  "Are  you  sure?"  "N'o." 
"  How  long  have  you  been  here  ? "  "  This  morning."  (He  has 
been'  here  six  years.)  He  cannot  reason,  he  has  almost  no 
affections,  caring  for  no  one,  showing  no  pleasure  in  seeing 
his  relations.  He  has  no  Avishes,  hopes,  or  fears,  and  little 
memory ;  ambition,  joy,  and  sorrow  are  dead  to  him.  He 
does  not  resist  anything,  and  has  no  choice  as  between  any 
two  things.  He  has  no  fineness  of  feeHng,  no  "tastes."  His 
habits  would  become  dirty  and  degraded  if  not  looked  after. 
Looked  at  from  the  purely  bodily  point  of  view,  he  has  no 
keen  appetite  at  all,  even  for  food,  for  he  has  been  several 
times  forgotten  in  the  garden  over  meal  times,  and  hunger  did 
not  bring  him  to  dinner.  He  has  no  proper  sexual  appetite, 
though  he  masturbates  in.  an  automatic  way.  His  temperature 
is  about  a  degree  and  a  half  below  the  normal,  his  circulation 
poor.  Ins  hands  blue  and  cold  in  chilly  weather,  his  muscles 
flabby,  his  common  sensibihty  much  diminished,  for  you  see 
pricking  with  a  pin  does  not  rouse  him  much.  His  digestion 
and  the  action  of  the  bowels  are  good  and  regular,  and  the 
sleep  power  of  his  brain  is  perfect,  in  fact  he  would  sleep  too 
long  if  allowed  to.  There  is  a  good  deal  of  flabby  fat  on  his 
body.  Sores  are  slow  in  heahng,  and  when  he  catches  cold 
he  scarcely  ever  coughs,  though  there  may  be  much  bronchial 
irritation.  The  reflex  action  of  the  cord  is  diminished,  though 
the  tendon  reflex  is  normal.  Last  of  all,  that  power  of  action 
and  power  of  co-ordination  of  those  marvellously  innervated 
strands  of  muscles  in  the  face  that  give  "  expression  "  to  the 
face  seem  to  be  utterly  dulled  and  diminished,  and  the  eyes 
are  expressionless.  It  is  clear  that  all  the  highest  quahties  of 
his  brain  are  gone,  and  that  even  the  lower  quahties  are  much 
enfeebled.  He  is  now  demented;  but  he  was  once  an 
intelhgent  educated  man,  who  had  an  attack  of  acute  mania, 
and  was  left,  after  that  had  passed  away,  as  you  see  liim. 


STATES   OF   MENTAL  ENFEEBLEMENT.  283 

There  are  five  chief  kinds  of  dementia : — 

1.  Secondary  {Ordinary  or  Sequential  or  Terminal)  Dementia, 
following  mania  and  melancholia  or  other  insanity. 

2.  Primary  Enfeehlement  {Congenital  Imhecility,  Idiocy, 
Amentia,  Cretinism),  the  result  of  arrested  brain  development, 
or  of  brain  disease  in  early  life. 

3.  Senile  Dementia. 

4.  Orgafiic  Dementia,  the  result  of  gross  organic  brain 
disease. 

5.  Alcoholic  or  Drug  Dementia,  following  the  long-continued 
excessive  use  of  alcohol,  or  of  neurotic  drugs  such  as  opium, 
cocaine,  chloral,  &c.  As  the  last  three  varieties  will  be  de- 
scribed under  the  headings  of  the  senile,  paralytic,  and 
alcholic  insanities,  I  shall  not  further  refer  to  them  here. 

I  have  purposely  omitted  a  variety  which  you  will  find 
in  all  the  text-books — "Acute"  or  "Primary"  Dementia — 
because  I  tliink  tliis  is  a  misnomer,  and  leads  to  much  con- 
fusion, besides  being  an  unscientific  nosology.  I  prefer  to 
classify  "  Primary  Dementia  "  under  Stupor. 

As  every  variety  of  real  dementia  is  incurable,  and  as  the 
medical  profession  outside  of  public  institutions  has  Mttle  to  do 
with  its  treatment,  I  shall  devote  little  time  to  it. 

Secondary  Dementia. — This  always  follows,  and  is  in  a  way 
"the  result  of"  more  acute  mental  disease,  such  as  mania  and 
melanchoha,  and  therefore  may  be  called  sequential.  It  is  the 
most  characteristic,  and  the  most  interesting  to  the  psychiatrist 
of  all  the  forms  of  mental  enfeehlement,  so  that  when  you 
hear  of  a  person  labouring  under  dementia  it  is  usually  this 
that  is  meant.  It  is  dementia  par  excellence,  therefore. 
It  is  the  goal  of  nearly  all  insanities  that  are  not  recovered 
from. 

When  a  condition  of  morbid  mental  exaltation,  especially 
when  this  has  been  acute  mania,  has  existed  for  a  long  time, 
we  find  that  the  over-action  usually  causes  a  tendency  to 
mental  weakness  as  the  exaltation  passes  away,  and  this  in 
some  cases  is  left  as  a  permanent  brain  condition.     This  is 


284  STATES   OF  MENTAL  ENFEEBLEMENT. 

dementia.  The  same  tendency  is  seen,  but  to  a  less  degree, 
as  tlie  result  of  a  prolonged  condition  of  mental  depression. 
This  is  the  termination  we  most  of  all  dread  in  acute  insanity. 
All  mental  diseases  when  long  continued  tend  towards 
dementia.  "When  the  matter  is  looked  at  pathogenetically 
it  might  be  thus  stated.  For  the  production  of  most  cases 
of  mental  disease  we  need  a  morbid  neurotic  heredity,  or 
prolonged  causes  of  irritation  or  exhaustion.  Then  comes  an 
exciting  cause  of  disturbance  strong  enough  to  convert  this 
tendency,  this  potentiality  into  an  actual  disease ;  or  this 
occurs  in  the  ordinary  course  of  the  development,  evolution, 
or  dissolution  of  a  hereditarily  weak  brain,  and  a  severe  out- 
burst of  abnormal  action  occurs  in  the  brain  convolutions. 
The  chief  symptoms  of  this  are  the  maniacal  exaltation 
or  the  melanchohc  depression.  The  abnormal  action  means 
abnormal  nutrition  as  well  as  abnormal  energising.  This 
abnormal  nutrition  tends  injuriously  to  affect  the  minute  and 
dehcate  neurine  structure,  the  capillaries,  the  lymphatics  and 
the  packing  tissue  of  the  grey  matter  of  the  convolutions. 
It  even  affects,  as  we  have  seen,  the  structure  of  the  surround- 
ings of  the  brain, — the  pia  mater,  the  large  vessels,  the 
arachnoid,  the  cerebro-spinal  fluid,  the  epithehum,  the  dura 
mater,  and  the  calvarium.  When  this  storm  of  morbid  action 
at  last  passes  off  or  exhausts  itself,  the  cells  in  some  cases 
have  become  so  damaged  that  they  are  no  longer  fit  to 
become  the  vehicles  of  normal  mentalisation — their  nutritive, 
their  storage  of  energy,  their  receptive,  and  their  productive 
power  being  impaired,  metabolism,  anabohsm,  and  katabohsm 
being  all  abnormal  in  them.  Dr  MacphaO.  has  shown  that  the 
constitution'^  of  the  blood  is  altered  in  dementia.  The  mental 
result  of  all  this  is  enfeeblement  or  dementia.  Analogous 
damage  to  function  occurs  in  coarser  forms  in  all  the  coarser 
tissues  and  organs,  e.g.,  the  permanent  damage  to  locomotion 
that  results  from  long-continued  rheumatic  inflammation  of 
a  joint,  to  digestion  from  prolonged  over-stimulation  of  the 
1  Jour.  Mcnt.  ScL,  Oct.  188i. 


STATES   OF   MENTAL   ENFEEBLEMENT.  285 

stomach,  to  sight  from  the  intense  lights  of  the  desert  or  the 
Alps,  to  hearing  from  the  continuous  clang  in  an  iron  ship- 
building yard.  You  will  remember,  however,  that  from 
the  very  beginning  there  was  probably  a  tendency  through  a 
bad  heredity  towards  that  weakening  of  the  mental  functions 
of  the  brain  which  we  call  dementia,  towards  mental  death, 
in  fact ;  and  there  are  many  cases  where  the  previous  excite- 
ment was  so  slight  or  so  short  that  we  must  conclude  that 
the  essential  nature  of  the  mental  disease  was  the  tendency  to 
dementia  from  the  beginning.  The  great  difference,  in  effect, 
between  partial  loss  of  function  in  the  brain  convolutions  and 
in  any  other  organ  of  the  body,  is  that  in  the  former  case  the 
man  dies  to  all  intents  and  purposes,  socially  his  right  even 
to  liberty  is  gone,  and  his  place  among  his  fellow-men  is  taken 
by  another. 

The  following  is  a  typical  case  of  secondary  dementia  : — E. 
B.,  a  handsome,  well-developed,  intelligent,  well-educated 
young  woman,  whose  mother  was  insane,  her  sister  a  woman 
that  "no  one  could  live  with,"  and  a  brother  a  confirmed 
drunkard,  had,  at  the  age  of  twenty-four,  a  cross  in  a  love 
affair.  At  first  she  was  depressed  in  spirits  for  a  few  months, 
then  she  took  to  a  morbid  eccentric  religionism,  and  in  six 
months  became  acutely  maniacal.  She  remained  so  for  a  year. 
At  the  end  of  that  time  her  whole  appearance  and  expression 
of  face  were  so  different  from  the  attractive  girl  she  had  been 
that  her  friends  scarcely  recognised  her  to  be  the  same  person. 
Her  face,  that  "mirror  of  the  soul,"  expressed  no  doubt  the 
fancies  and  the  passions  that  were  evolved  in  her  morbid 
brain,  but  there  was  also  a  vacancy  and  a  physiological  degra- 
dation very  manifest.  About  that  time  she  began  to  sleep 
better,  then  to  eat  better,  then  to  talk  and  scream  less,  then 
to  be  able  to  sit  still  longer  and  control  herself  more.  This 
process  of  gradual  quiescence  went  on  for  six  months,  with 
occasional  spurts  of  exaltation  and  short  relapses  into  active 
mania.  By  that  time  she  was  getting  fat,  sluggish,  devoid  of 
interest  in  anything,  and  with  no  emotion.     She  did  not  ask 


286  STATES   OF  MENTAL  ENFEEBLEMENT. 

for  those  who  had  been  dearest  to  her,  or  exliibit  any  pleasure 
when  they  came  to  see  her.  She  often  laughed  and  talked 
to  herself.  Her  speech  and  conduct  were  best  described  as 
very  "silly."  Her  memory  seemed  gone.  All  that  education 
had  done  for  her  brain  seemed  to  have  disappeared,  or  could 
only  be  brought  out  in  disjointed  incoherent  scraps.  The 
nameless  charms  of  dress  and  manner  and  behaviour  of  a 
bright  young  lady  had  absolutely  disappeared.  She  was 
slovenly  and  not  over  cleanly,  showed  few  Hkes  or  dishkes, 
and  no  will  of  her  own.  Her  face  was  vacant,  her  eyes 
expressionless,  her  motions  slow  and  wanting  in  purpose  and 
vigour,  and  her  nutrition  flabby.  She  slept  well,  she  ate  very 
well  but  with  little  choice  of  foods,  her  digestion  was  good, 
her  bowels  regular,  and  her  menstruation,  which  had  ceased 
during  the  whole  of  the  maniacal  period,  became  regular. 
She  is  in  fact  dead  to  mental  life  in  any  proper  sense,  and  so 
has  remained  now  for  many  years,  and  so  will  remain  till  she 
dies  of  some  disease  that  will  not  necessarily  be  a  brain  disease 
at  all.  Her  chances  of  life  are  probably  below  those  of  a  sane 
person  at  her  age,  but  she  may  Hve  long.  These  are  the 
cases  that  form  the  bulk  of  the  old  inmates  of  asylums,  and 
about  whom  their  friends  say  they  seem  to  outhve  all  their 
sane  relations  and  friends,  because  they  are  free  from  the 
worries  and  cares  of  Hfe,  and  live  a  regulated  existence  under 
medical  rule. 

In  certain  things  E.  B.  did  improve  after  the  first  two  years. 
Her  brain  was  subjected  to  a  re-education  of  a  simple  kind, 
but  its  capacity  for  this  was  limited.  It  had  no  power  of 
acquiring  any  sort  of  high  attainment  in  anything.  She  was 
taught  to  dress  herself  more  neatly,  to  do  a  httle  simple  work, 
to  observe  certain  hours  for  meals,  &c.  Curiously  enough 
certain  mechanical  achievements  in  which  she  had  been  well 
educated,  so  that  they  had  become  the  automatic  property  of 
the  motor  brain  centres,  came  back  to  her  easily,  and  were 
well  done.  Such  were  certain  kinds  of  ladies'  work  and 
sewing.     It  was  found  she  could  play  some  of  her  old  tunes 


STATES  OF  MENTAL  ENFEEBLEMENT.  287 

on  the  piano,  but  the  music  was  mechanical.  All  the  life  and 
soul  was  out  of  it.  She  could  not  be  taught  the  simplest  of 
new  tunes,  no  new  stitching,  no  new  dance  steps.  Every  now 
and  again  she  has  a  shght  return  of  the  maniacal  exaltation, 
beginning  usually  at  a  menstrual  period,  and  at  the  very 
beginning  of  one  of  these  she  will  look  and  act  more  like  her 
sane  self  than  at  any  other  time.  She  is  placed  under  the 
control  of  social  inferiors,  and  she  does  not  resist.  She  lives 
in  the  Asylum,  and  she  does  not  ask  why.  She  has  no  money, 
and  she  does  not  seek  it.  She  forms  no  attachment,  and  she 
associates  with  strangers  without  feeling  it. 

Varieties. — This  is  the  type  of  all  the  cases  of  secondary 
dementia  in  its  causes  and  symptoms.  But  there  is,  of  course, 
great  variety  in  the  details  of  the  clinical  pictures.  Attacks 
of  melancholia  may  be  followed  by  dementia,  but  this  is  not 
nearly  so  common  as  in  the  case  of  mania,  except  in  certain 
senile  cases.  Nothing  more  conclusively  shows  that  conditions 
of  depression  are  essentially  less  profound  departures  from 
mental  health  than  conditions  of  exaltation,  than  the  lesser 
tendency  to  dementia  after  the  former.  When  it  does  occur 
it  is  a  less  complete  dementia  than  occurs  after  mania,  and  is 
nearly  always  tinged  with  a  melancholic  cast.  Out  of  100  cases 
of  dementia  taken  at  random,  whose  histories  I  know,  only  20 
followed  melancholia.  All  sorts  of  partial  dementia  occur.  I 
have  many  patients  in  the  Asylum  who  look  like  other  people, 
who  converse  with  you  rationally  when  you  talk  with  them, 
and  have  no  delusion,  but  they  have  no  initiative,  no  origin- 
ating power,  no  active  desires,  no  power  of  self-guidance  or 
resistive  capacity.  I  sent  such  a  man  out  of  the  Asylum  lately, 
and  he  just  sat  down  at  home,  would  not  work,  would  scarcely 
get  out  of  bed,  cared  nothing  for  cleanliness  and  the  decencies 
of  life,  and  only  earned  ten  shillings  the  six  months  he  was  out. 
Some  persons  in  this  state  do  some  work  in  the  world  outside 
under  suitable,  interested,  and  kindly  guidance.  Sometimes  a 
man  is  left  after  a  maniacal  attack  mentally  twisted,  or  has 
a  curious  mixture  of  enfeeblement  and  obstinacy.     I  know  a 


288  STATES   OF  MENTAL  ENFEEBLEMENT. 

gentleman  who  once  had  an  attack  of  mania,  and  who  now 
shows  a  mild  dementia  chiefly  in  either  defying  or  being  un- 
conscious of  the  conventionahties  of  life.  He  goes  about  the 
streets  often  in  a  dressing-gown  and  shppers,  he  pays  no  defer- 
ence whatever  to  ladies,  he  eats  at  irregular  hours,  is  "never  to 
be  depended  upon  "  in  anything,  and  yet  he  manages  his  affairs 
and  seems  happy  in  a  way.  In  some  cases  a  man  shows  mild 
dementia  by  shght  degradations  in  his  habits  and  feehngs. 
I  know  such  a  man  who  is  simply  not  so  sensitive  as  he  once 
was,  not  so  particular  in  small  things,  is  content  with  worse- 
fitting  clothes,  and  is  not  so  neat  and  clean  in  his  ways.  I 
know  another  case  where  it  shows  itself  by  what  his  friends 
call  excessive  laziness.  He  will  not  walk  or  work,  or  do  any- 
tliing,  in  fact,  but  sit  in  the  house  and  smoke.  I  know  many 
cases  where  it  shows  itself  in  deficient  inliibitory  power  over 
the  appetites,  the  patients  taking  to  drinking  and  sexual  im- 
morality. Indeed  one  might  say  that  the  "  moral  faculties  " — 
if  by  these  are  meant  the  combined  feehng  of  repugnance  to 
what  is  wrong  and  the  power  to  avoid  it — are  the  first  to  be 
affected  in  dementia.  Such  high  moral  attributes  being  the 
last  to  appear  in  the  evolution  of  man,  are,  as  Dr  Savage  rightly 
puts  it,  the  first  to  disappear  in  certain  morbid  mental  states. 
In  other  cases  the  patients  simply  sink  into  a  lower  social 
stratum,  and  evidently  are  more  happy  there  than  in  their 
own.  Such  cases  are  commonly  reckoned  as  being  examples 
of  mere  eccentricity,  but  they  are  scientifically  cases  of  partial 
or  limited  enfeeblement  of  mind. 

Tilings  that  are  of  the  greatest  hivportance  in  relation  to 
secondary  dementia. — 

1.  The  period  of  life  during  wliich  the  primary  attack  of 
mania  or  melancholia  occurs  is,  in  my  opinion^  of  primary  im- 
portance. Much  more  than  half  of  all  the  terminal  dementia 
follows  the  insanity  of  adolescence. 

2.  The  risk  of  dementia  is  in  certain  cases  in  direct  ratio  to 
the  length  of  the  maniacal  exaltation.  This  does  not  quite 
apply  to  melancholic  depression,  the  existence  of  which  for 


STATES   OF  MENTAL  ENFEEBLEMENT.  289 

long  periods  is  not  so  damaging  to  convolution  function. 
Beyond  a  doubt  there  are  some  cases  that  become  demented 
after  only  a  few  weeks  of  maniacal  excitement,  when  in  fact 
it  is  clear  that  the  tendency  to,  it  was  present  from  the 
beginning,  and  when  it  was  an  inevitable  doom  of  their  brains. 
These  are  the  brains  which  seem  to  have  innate  energising 
power  in  them  to  last  only  for  so  many  years,  and  then  they 
fail  and  die  as  to  their  higher  mental  functions.  Of  course,  it 
may  be  asked,  How  do  we  know  that  this  is  not  the  case  in 
all  those  that  become  demented,  without  reference  to  the 
preceding  mania  at  all  ?  May  not  the  mania  simply  be  one 
incident  on  the  road  to  mindlessness,  and  not  the  cause  of  the 
latter  at  all?  I  am  convinced  this  is  so  in  many  cases,  but 
the  facts  of  a  great  number  of  cases  make  one  conclude  that 
a  maniacal  attack  does  tend  to  damage  the  brain  convolu- 
tions, and  that  the  longer  it  lasts  the  more  likely  is  that 
damage  to  be  permanent.  There  are  exceptional  cases,  how- 
ever, that  are  maniacal  for  years  and  yet  recover. 

3.  The  character  of  the  primary  attack  influences  the 
tendency  to  dementia  as  well  as  its  duration.  The  more  acute 
the  attack  the  greater  tendency  there  is  to  subsequent  mental 
enfeeblement.  But  to  this  rule  there  are  many  exceptions. 
I  have  now  a  case,  quite  demented,  where  the  primary 
maniacal  attack  was  very  mild, — only  amounting  to  simple 
mania,  and  that  lasting  but  for  a  month  or  so.  Then  enfeeble- 
ment showed  itself,  and  slowly  progressed,  till  in  four  years 
there  was  deep  dementia.  I  have  even  seen  a  few  cases  where 
a  mental  enfeeblement  began  ab  initio  without  mania,  without 
melanchoha,  without  gross  organic  disease  or  epilepsy  or 
alcohoUsm.  Such  cases  are  very  rare  indeed,  however,  but  of 
profound  interest.  We  can  usually  get  evidence  of  some 
symptoms  of  mania  or  melancholia  if  we  have  the  means  of 
ascertaining  correctly  the  patient's  state.  The  habit  of 
masturbation  may  cause  dementia  as  a  primary  mental 
disease  in  young  people  with  a  strong  neurotic  heredity, 
without    preliminary    mania,   and    the    continuous    abuse    of 

T 


290  STATES   OF  IVIEXTAL  ENFEEBLEMENT. 

alcoliol   or   nervine    stimulants   or   sedatives   may   liave   the 
same  effect. 

4.  The  number  of  previous  attacks  is  no  doubt  of  much 
importance  in  the  prehminary  history  of  dementia,  except  in 
the  case  of  those  typical  examples  of  alternating  insanity 
called  folie  circulaire  which  I  have  described.  The  case  of 
D.  B.  (p.  228),  whose  brain  had  over  two  hundred  attacks  of 
acute  maniacal  excitement  in  forty  years,  and  yet  did  not 
become  wholly  demented,  was  a  most  striking  example  of  the 
recuperative  power  of  the  brain  cortex.  Speaking  generally, 
the  tendency  to  dementia  increases  in  each  successive  attack. 
The  relapsing  tendency  of  adolescent  insanity  is  to  my  mind 
an  illustration  of  the  two  inherent  tendencies  in  such  brains, 
— the  one  to  mental  recovery  and  hfe,  the  other  to  mental 
death.  And  we  notice  that  the  sooner  the  relapsing  tendency 
stops  the  more  likely  is  the  former  result  to  occur.  It  often 
happens  that  after  a  first  attack  of  insanity  certain  mental 
pecuharities  are  left,  seen  it  may  be  only  by  the  patient's  near 
relations  and  intimate  friends.  He  is  not  "quite  the  same 
man."  Each  succeeding  attack  that  he  has  leaves  him  with 
more  marked  pecuharities  or  weaknesses,  until  the  final  irre- 
parable breakdown  of  dementia  is  reached.  You  will  con- 
stantly be  asked  your  opinion  of  a  man  who  has  once  been 
insane,  to  hold  appointments,  to  accept  trusts,  to  contract 
marriage,  &c.  One  must  frequently  give  a  guarded  answer, 
and  this  not  only  after  examination  yourself,  but  after  minute 
inquiry  from  disinterested  friends  who  have  seen  most  of  him. 
I  find  it  often  more  difficult  to  pronounce  a  man  sane  than  to 
pronounce  bim  insane.  There  is  no  doubt  that  a  man  may 
fully  and  perfectly  recover  from  attacks  of  insanity.  They 
may  leave  not  a  trace  behind  them  in  any  shape  or  form.  I 
could  point  to  hundreds  of  men  and  women  who  have  been 
insane,  and  who  now  do  their  work  as  well  as  ever  they  did. 
It  is  a  grave  injustice  to  regard  all  men  who  have  been  insane 
as  tainted  and  unfit  to  hold  appointments  of  trust,  though  this 
is  unfortunately  a  common  prejudice.     There  is   a  risk,  no 


STATES   OF  MENTAL  ENFEEBLEMENT.  291 

doubt,  but  it  would  be  indeed  a  terrible  thing  if  mental 
diseases  were  regarded  as  necessarily  implying  an  incurable 
mental  deficiency  or  a  relapse  some  day. 

5.  The  next  element  that  affects  the  occurrence  of  dementia, 
and  that  we  have  to  take  into  account,  is  the  heredity  of  the 
patient.  The  common  opinion  undoubtedly  is,  both  among 
the  profession  and  general  pubHc,  that  a  strong  family  pre- 
disposition to  insanity  means  a  bad  chance  of  recovery  in  any 
particular  attack, — in  other  words,  a  tendency  to  dementia. 
Now  this  is  not  true  as  a  matter  of  fact.  Strongly  hereditary 
cases  are  the  most  curable  of  all,  but  they  are  most  hable  to 
recur ;  though  many  of  them  are  undoubtedly  incurable  from 
the  beginning.  A  strong  and  direct  heredity  implies  four 
things — (a)  instability  of  brain,  (b)  Kability  to  attacks  at  early 
ages,  (c)  liability  to  a  recurrence  after  cure,  and  (d)  typical 
dementia  in  many  of  the  cases  after  one  or  more  attacks 
especially  in  the  adolescent  cases. 

6.  There  is  a  state  of  mental  weakness,  that  frequently 
follows  sharp  attacks  of  mania  and  melancholia,  which  closely 
resembles  dementia,  and  yet  is  quite  curable.  It  is  in  reality 
a  mUd  form  of  "secondary  stupor,"  and  I  shall  treat  it  under 
that  heading.  It  is  analogous  to  the  stage  of  temporary 
exhaustion  and  reaction  that  follows  many  acute  diseases. 
It  is  the  period  of  functional  rest  but  trophic  activity,  during 
which,  through  the  vis  medicatrix  naturoe,  organs  that  have 
been  diseased  heal,  tissues  whose  nutrition  has  been  disturbed 
eliminate  morbid  elements  and  become  normal,  and  functions 
that  have  been  altered  or  suspended  resume  slowly  their 
activity.  This  period  is  of  the  highest  importance  for  treat- 
ment. 

Treatment  of  Dementia.  —  Eegulated  activity,  nutritives, 
tonics,  sometimes  stimulants,  and  counter-irritants  are  indi- 
cated in  the  early  stage.  It  is  the  time  for  the  use  of  the 
stimulating  nerve  tonics  and  vaso-motor  stimulants,  such  as 
strychnine,  quinine,  iron,  phosphorus,  the  phospliates  and 
hypophosphites,  shower  baths,  friction  to  skin,  the  interrupted 


292  STATES  OF  MENTAL  ENFEEBLEMENT. 

and  continued  currents,  Turkish  baths  followed  by  brisk 
shampooing,  and  bhsters  to  the  back  of  the  head.  I  have 
a  man  who  had  become  dull,  stupid,  and  lethargic  after  an 
attack  of  acute  mania,  "  wakened  up "  visibly  under  such 
treatment.  I  had  a  young  woman  who  had  ceased  to  speak, 
rouse  up  and  begin  talking  and  working  immediately  after 
a  blister  had  been  apphed  to  the  back  of  her  head.  I  had 
a  man  who  roused  up,  not  only  in  mind  but  in  muscular 
activity  and  in  vaso-motor  force,  his  hands  getting  warm 
instead  of  blue,  under  the  use  of  Parrish's  syrup.  This  was 
stopped  in  a  fortnight  and  he  at  once  fell  back.  It  was  re- 
newed and  he  picked  up,  and  again  stopped  and  he  fell  back. 
It  was  given  continuously  for  three  months  tiU  he  recovered 
completely.  The  use  of  thyroid  extract,  given  in  large  doses, 
as  recommended  by  Dr  Lewis  Bruce,  is  of  extraordinary 
efficacy  in  some  cases  for  preventing  the  occurrence  of 
dementia.  I  now  am  never  satisfied  that  all  has  been  done 
in  any  case  threatened  with  dementia  till  a  course  of  thyroid, 
has  been  tried.  When  dementia  is  confirmed,  a  regulated 
physiological  Kfe,  control,  order,  system,  cleanhness,  exercise, 
suitable  emplayments  and  amusements,  tend  to  prevent  further 
deterioration. 

After  a  very  careful  study  of  dementia  in  all  its  relations, 
I  have  come  to  the  following  conclusions  :  ^ — 

1.  Normal  brain  cortex  difi'ers  enormously  in  different 
individuals  in  its  inherent  qualities  and  potentiahties,  these 
differences  being,  as  far  as  our  present  knowledge  goes, 
"functional." 

2.  The  strongest  chnical  and  psychological  connection 
of  every  form  of  mental  disease  is  the  tendency  to  end 
in  dementia. 

3.  Dementia  being  a  virtual  death  of  the  higher  mental 
powers,  all  insanities,  therefore,  may  mean  mind  death  and 
social  death. 

4.  Dements  constitute  two-thirds  of  oiu'  insane  population. 

^  "  Secondary  Dementia,"  Jour.  Ment.  Sci.,  Oct.  1888. 


STATES   OF   MENTAL   ENFEEBLEMENT.  293 

5.  Forty  out  of  every  hundred  of  all  new  cases  of  insanity 
soon  pass  into  secondary  dementia  pure  and  simple  or  mixed 
up  with  maniacal  or  delusional  conditions. 

6.  The  functional  change  that  takes  place  in  the  brain 
cortex  in  secondary  dementia  is  primarily  and  chiefly  con- 
fined to  the  mind  tissue,  and  is,  in  fact,  a  unique  disease 
in  nature  with  no  strict  pathological  analogies, 

7.  The  problem  of  what  secondary  dementia  means  and 
how  it  can  be  averted  is  the  cardinal  problem  of  psychiatry. 

8.  Mental  disease  might  even  be  defined  as  "a  tendency 
to  dementia." 

9.  The  constant  association  with  dements  alone  tends  to 
lower  the  mental  tone  of  the  staffs  of  asylums  by  the  well- 
known  law  of  the  action  of  mind  on  mind. 

10.  Secondary  dementia  has  as  yet  no  sufficient  patho- 
logical explanation,  but  recent  researches  point  to  cortical 
cell  degeneration. 

11.  It  may  be  looked  on  as  a  reversion  of  type,  as  a 
premature  functional  death  of  the  mind  tissue,  or  as  a  most 
beneficial  result  of  the  laws  that  bring  a  bad  stock  to  an  end. 

12.  Eeal  secondary  dementia  may  be  so  closely  imitated 
by  secondary  stupor  that  only  time  and  the  effects  of  treat- 
ment can  distinguish  them.  We  may  look  on  the  primary 
maniacal  attack  as  threatened  dementia,  and  the  secondary 
stupor  as  being  that  threat  partly  carried  into  execution. 

13.  We  have  no  reason  to  think  that  a  brain  which  has 
a  perfectly  sound  heredity  can  by  any  series  of  bad  con- 
ditions known  to  us  be  made  to  pass  into  typical  secondary 
dementia, 

14.  The  impressions  through  the  senses  from  the  outer 
world  do  not  stimulate  normally  the  mental  cortex  of  a 
dement,  though  if  the  stimulant  is  very  strong  a  certain 
response  is  obtained,  but  such  a  brain  is  incapable  of  pro- 
viding such  a  stimulus  by  its  own  inherent  working. 

15.  Dementia  cannot  be  looked  on  as  entirely  caused  by 
the  damage  done  to  the  mind  tissue  through  the  primary 


294  STATES   OF   MENTAL   ENFEEBLEMEXT. 

acute  disturbance,  for  it  sometimes  occurs  "without  an 
acute  primary  stage,  and  its  occurrence  "bears  no  definite 
relationship  to  the  intensity  or  the  duration  of  the  primary 
attacks. 

16.  Most  of  the  cases  of  chronic  and  delusional  mania 
have  also  some  amount  of  dementia  superadded. 

17.  The  pathological  appearances,  naked  eye  and  micro- 
scopic, found  in  the  hrain  cortex  in  long-continued  cases  of 
dementia  are  capahle  of  possible  explanation  on  the  theory  of 
the  degeneration  and  atrophy  of  long  disused  tissue ;  hut  more 
probably  they  are  the  advanced  stage  of  the  pathological 
condition,  ■which  is  the  real  cause  of  the  dementia,  but  which 
in  its  early  stage  we  cannot  as  yet  recognise. 

18.  ISo  merely  vascular  theory  of  dementia  is  tenable. 

19.  Typical  secondary  dementia  always  has  a  neurotic 
heredity,  and  its  genesis  can  often  be  traced  through  the 
stages  of  hyper-activity,  hyper-sesthesia,  diminished  inhibition, 
instabihty,  melanchoha,  mania,  and  alternation  in  different 
generations,  or  in  members  of  the  same  generation  affected 
in  different  degrees. 

20.  Pure  and  uncompKcated  secondary  dementia  does  not 
readily  supervene  on  the  insanities  that  occur  after  full 
development  and  before  the  period  of  decadence,  such  as 
puerperal  and  lactational  insanities,  or  those  resulting  from 
overwork  or  emotional  causes  at  that  age. 

21.  Melancholic  and  alternating  insanities,  delusional  and 
inhibitory  insanities  are  not  the  preliminary  stages  of  secondary 
dementia  nearly  so  frequently  as  maniacal  attacks. 

22.  Most  of  the  pure  and  typical  cases  of  secondary 
dementia  will  be  found  to  have  originated  in  the  develop- 
mental— pubescent  and  adolescent — insanities. 

23.  Masturbation  may  be  an  element  in  the  production  of 
secondary  dementia  in  some  cases,  but  it  is  not  a  necessary 
or  a  constant  cause. 

24.  Idiocy  and  congenital  imbecility  represent  nature's 
failures  during  brain  growth,  while  secondary  dementia  is 


STATES   OF  MENTAL  ENFEEBLEMENT.   '  295 

the  typical  failure  during  development  of  brain  function  after 
full  weight  has  been  attained. 

25.  Pure  secondary  dementia  means  that  the  organism  has 
failed  in  its  most  highly  organised  structure  and  in  its  most 
important  function  just  at  the  point  before  full  reproductive 
perfection  should  have  naturally  been  reached. 

26.  Undue  and  unphysiological  stimulus  through  a  forcing- 
house  mode  of  education  during  adolescence  without  regard 
to  the  hereditary  capacity  and  weaknesses  of  the  organism 
may  tend  towards  dementia. 

27.  The  constant  changes  in  each  generation  of  modern 
civilised  life  in  the  adaptation  of  the  human  organism  to  its 
environments  and  the  special  efforts  thus  rendered  necessary 
by  the  struggle  for  existence  tend  towards  dementia  through 
the  strain  they  put  on  the  mind  tissue,  the  most  delicate  of 
all  organised  tissues  in  hereditarily  predisposed  subjects. 

28.  Adolescent  insanity  ending  in  secondary  dementia  may 
be  regarded  as  the  typical  form  of  mental  disease. 

29.  Dementia  would  have  seemed,  but  is  not,  a  more 
natural  sequence,  of  the  insanities  of  decadence — climacteric 
and  senile — than  of  any  others,  for  in  them  it  would  be  a 
mere  anticipation  of  the  reproductive  and  mental  death  that 
has  physiologically  begun. 

30.  The  lower  animals,  while  subject  to  attacks  analogous 
to  melanchoha  and  mania,  are  not  subject  to  any  state  corre- 
sponding to  secondary  dementia  before  the  senile  period. 

31.  By  prophylaxis  in  some  cases,  and  by  right  treatment 
of  the  primary  attack  in  others,  dementia  may  be  averted, 
but  in  many  cases  it  is  inevitable  through  the  bad  heredity  of 
the  individual. 

Primary  Enfeeblement  {Idiocy,  Congenital  Imhecility,  Amen- 
tia).— I  do  not  propose  to  say  much  about  primary  mental 
enfeeblement,  but  rather  to  glance  at  a  few  of  the  most 
typical  varieties.  Ireland's^  definition  is  that  "idiocy  is  a 
mental  deficiency  or  extreme  stupidity,  depending  upon  mal- 
^  Idiocy  and  Imhecility,  by  W.  W.  Ireland,  M.  D. 


296  STATES   OF   MENTAL   EXFEEBLEMENT. 

nutrition  or  disease  of  tlie  nervous  centres  occurring  eitlier 
before  birth  or  before  the  evolution  of  the  mental  faculties  in 
childhood."  "Imbecihty  is  generally  used  to  denote  a  less 
decided  degree  of  mental  incapacity."  In  short,  idiocy  and 
imbecility  are  conditions  of  mental  enfeeblement  resulting 
from  arrested  brain  development  before  bu'th  or  in  very 
early  childhood.  The  mental  faculties  were  never  there, 
their  organ  being  unfit  to  manifest  them.  In  dementia, 
as  we  have  seen,  they  were  destroyed  or  enfeebled  in  a 
previously  normal  individual.  It  is  weU  to  bear  in  mind 
certain  things  in  regard  to  idiocy.  1.  That  there  are  great 
varieties  of  the  condition,  both  as  to  symptoms,  causes, 
treatment,  educabihty,  and  prognosis.  2.  That  the  mental 
deficiency  is  always  accompanied  by  bodily  weakness  of 
some  sort, — tropliic,  resistive,  and  motor, — which  can  often 
be  treated  with  good  effect  by  the  ordinary  resources  of 
our  profession.  This  is  well  proved  by  this  fact,  that  two- 
thirds  of  the  cases  die  of  tuberculous  affections.  3.  That  by 
heredity  and  pathological  connection  it  is  apt  to  be  associated 
with  scrofula,  tuberculosis,  drunkenness,  insanity,  and  crime. 
4.  That  the  main  instruments  of  treatment  must  be  a  general 
bodily  and  mental  education  of  a  special  kind,  adapted  to  the 
physiological  educabihty  and  potentiahties  of  the  individual 
brain  under  treatment,  with  often  special  conditions  of  diet, 
clothing,  control,  and  modes  of  life.  This  can  usually  be  best 
attained  in  a  special  institution. 

Congenital  Imhecility. — This  may  exist  in  every  degree, 
from  the  smallest  amount  of  mental  weakness  down  to 
idiocy.     Here  is  a  fairly  common  case  : — 

E.  C,  now  25,  of  a  family  in  which  both  drunkenness  and 
insanity  had  occurred.  When  a  child  he  was  well  developed, 
and  apparently  hke  other  cliildren,  till  he  was  about  three  or 
four  years  of  age,  when  it  was  noticed  that  he  was  not  so 
bright,  not  so  imitative,  and  not  so  observant  as  a  child  at 
that  age  should  be.  Speech  was  long  in  coming  and  difficult 
to  learn.     As  he  grew  older  he  could  learn  almost  nothing  at 


STATES   OF   MENTAL   ENFEEBLEMENT.  297 

school;  liis  school-fellows  annoyed  him,  and  he  showed  un- 
governable passion  and  violence.  The  faculty  of  inhibition 
is  almost  always  weak  in  imbeciles,  but  they  are  not  all 
passionate  or  ungovernable.  At  puberty  he  got  much  more 
difficult  to  manage  at  home,  and  all  his  weaknesses  and 
peculiarities  were  thus  more  observable.  Unfortunately  he 
was  not  sent  to  a  special  institution  or  home  for  the  training 
of  imbeciles.  He  could  then  have  been  taught  much  more 
than  he  now  knows.  In  fact,  I  see  no  reason  why  he  should 
not  have  learned  some  trade  or  mechanical  work,  and  done  it 
in  a  sort  of  way.  He  got  so  irritable,  and,  when  in  a  passion, 
so  violent,  that  he  had  to  be  sent  here  about  ten  years  ago. 
He  has  settled  down  into  the  life  and  routine  of  the  place,  is 
cleanly,  tidy,  and  orderly  in  his  habits,  industrious  in  simple 
matters,  such  as  bed-making,  floor- wasliing,  but  is  still  very 
passionate  and  impulsive.  He  is  happy  and  contented,  and 
has  no  unfulfilled  ambitions  nor  longings  to  satisfy.  Look 
at  him.  He  is  fairly  developed,  but  his  hard  palate  is  narrow 
and  V-shaped  (see  Plate  XI.).  At  ten  yards'  distance  you 
would  say  he  was  an  ordinary-looking  young  man.  When 
you  observe  him  closely  you  see  there  is  a  weakness  in  his 
expression  of  face,  a  lack  of  mind  in  his  eye,  and  a  sort  of 
shuffle  in  his  walk,  while  all  his  movements  lack  purpose  and 
conciseness.  When  he  smiles  he  looks  silly,  and  his  speech 
is  rather  defective.  You  see  at  once  there  is  no  force  in  him 
of  any  sort,  motor  or  mental.  When  further  tested,  his 
memory  is  seen  to  be  defective,  he  cannot  tell  you  how  much 
four  added  to  four  and  two  off  is.  He  can  write,  but  like  a 
schoolboy.  You  see  that  he  is  unfit  to  guide  himself,  to 
manage  liis  aff'airs,  to  earn  unaided  his  livehliood,  or  to  resist 
any  sort  of  temptation  put  in  his  way.  He  is  in  good  bodily 
health,  eats  and  sleeps  well,  enjoys  simple  pleasures  like  danc- 
ing, concerts,  and  jugglers'  entertainments,  and  may  Hve  long. 
E.  C,  is  a  good  type  of  the  most  common  form  of  con- 
genital imbecile.  There  are  others  where  one  has  much 
more   difficulty   in    determining   whether    they   shall   enjoy 


298  STATES   OF   MENTAL   ENFEEBLEMENT. 

civil  rights  and  liberty,  be  allowed  to  marry,  &c.,  being  very 
near  the  minimum  legally  sane  line.  Such  persons  often 
become  the  dupes  of  designing  people,  cannot  resist  tempta- 
tion or  control  natural  desires,  and  so  are  the  worst  kind  of 
dipsomaniacs.  Some  imbeciles  show  special  talent  in  certain 
directions, — some  in  music,  some  in  drawing,  some  in  imita- 
tion, some  in  a  kind  of  constructiveness ;  some,  who  are  of 
the  criminal  class,  are  bad  and  depraved  from  the  beginning 
— are  born  imbecile  criminals.  As  to  treatment,  the  great 
things  are,  carefuUy  to  develop  the  body,  to  keep  it  always  fat, 
not  to  give  much  animal  food  or  stimulating  diet,  especially 
at  puberty,  to  train  in  good  habits — bodily,  mental,  and 
moral, — to  make  their  lives  systematic  and  orderly,  to  avoid 
occasions  of  ill-temper,  to  punish  justly,  usually  by  deprivation 
of  indulgences,  to  send  to  institutions  for  training  and  not 
to  ordinary  lunatic  asylums  till  this  is  unavoidable. 

We  find  all  sorts  of  bodily  malformations,  asymmetries, 
dwarfishness,  and  ugliness  among  congenital  imbeciles,  these 
all  being  developmental.^ 

Congenital  imbeciles  may  have  attacks  of  maniacal  excite- 
ment or  melanclioKc  depression — in  fact,  are  subject  to  them. 
They  may  become  impulsive,  dangerous,  and  even  homicidal ; 
they  may,  after  an  attack,  have  secondary  stupor,  or  may 
become  demented  as  compared  with  their  primitive  condition. 
They  are  often  terrible  masturbators. 

Idiocy. — I  find  the  most  useful  classification  of  idiocy  is 
that  of  Dr  Ireland,  viz.: — 1,  Genetousj  2,  eclampsic;  3, 
epileptic  j  4,  paralytic ;  5,  inflammatory ;  6,  traumatic ;  7, 
microcephaHc ;  8,  hydrocephalic;  9,  by  deprivation  of  the 
senses;   and  10,   cretinism. 

Genetous  idiocy  is  that  variety  that  begins  before  birth. 
E.  D.  is  a  very  unfavourable  case.  She  is  now  twenty-four, 
and  never  showed  any  mental  potentiahty  at  aU  from  the 
beginning.  She  showed  no  affection,  no  clinging  to  any 
one  in  particular,  not  even  like  that  of  a  dog  to  those  who 
^  Vide  Author's  Neuroses  of  Development. 


STATES   OF  MENTAL  ENFEEBLEMENT.  299 

fed  her  and  were  kind  to  her.  She  has  never  had  any 
understanding  of  anything,  never  could  speak,  always  grunted 
in  that  animal-like  way  you  hear,  never  showed  curiosity, 
imitativeness,  nor  power  of  attention.  You  see  her  body  is 
squat  and  ugly,  her  temperature  low,  her  palate  deformed, 
high,  and  V-shaped,  and  her  teeth  irregular  and  few  in 
number.  She  has  from  childhood  beaten  her  head  with 
her  hands,  as  you  see  her  now  doing,  just  as  the  gorillas 
beat  their  breasts  in  the  African  woods.  Her  face  is  utterly 
unhuman,  hence  such  cases  have  been  called  theroid  or  beast- 
like. The  evolutionists  would  find  many  proofs  of  reversion 
to  conditions  common  in  the  lower  animals  in  her.  When 
you  place  a  tumbler  of  water  on  the  floor  before  her,  you 
see  she  kneels  down  and  laps  it  with  her  tongue.  She  has 
not  a  rudimentary  sense  of  decency  or  sexual  propriety. 
Such  a  case  is  beyond  the  reach  of  teaching  or  training  of 
any  sort.  Nothing  can  be  done  but  to  feed  and  clothe  her 
and  keep  her  clean. 

The  next  case  of  E.  E.  is  a  much  more  hopeful  subject. 
He  too  is  a  genetous  idiot,  and  is  small,  ill-developed,  rather 
deformed,  bandy-legged,  cold,  feeble  in  muscle  and  trophic 
power,  but  he  in  a  way  understands  some  things  you  say 
to  him,  is  always  smiling,  is  gentle,  has  been  taught  to  be 
cleanly  and  almost  tidy.  He  has  no  sexual  feelings,  cannot 
read  nor  write  nor  count,  and  will  probably  die  of  consump- 
tion. 

There  is  a  very  distinct  and  interesting  variety  of  genetous 
idiots  called  "Kalmuck,"  having  oblique  eyes,  small  round 
heads,  and  large  deeply  scored  tongues. 

The  genetous  variety  forms  the  largest  class  of  idiots,  varies 
greatly  in  the  mental  capacity  present,  and  many  of  them 
can  be  trained  in  training  schools,  and  made  more  human 
and  comfortable. 

The  edampsic  idiots  are  those  whose  brains  have  been 
injured  and  their  development  afterwards  retarded  by 
convulsions  at   dentition.     They  are    an   unfavourable  class 


300  STATES   OF   MEXTAL   ENFEEBLEMEXT. 

as  regards   training.     The   damage   done   to   the   brain  and 
its  envelopes  is  usually  demonstrahle  after  death. 

I  produce  hefore  you  a  whole  series  of  epileptic  idiots. 
Their  characteristics  are — \st,  that  they  vary  in  mental 
condition  very  much  according  to  whether  they  are  taking 
fits  or  not  at  the  time ;  and,  2nd,  that  the  efi'ect  of  the 
constant  recurrence  of  the  epileptic  seizures  is  such  on  the 
brain  that  it  tends  to  lose  the  effects  of  training  and  to 
deteriorate. 

Take  this  example  of  !E.  F.,  now  16,  who  has  taken  fits 
since  he  was  a  year  old.  At  times  he  is  gentle  and  teachable, 
and  works  in  the  garden,  and  enjoys  life;  then  he  will  have 
a  few  epileptic  fits,  and  he  will  be  stupid,  dirty  in  his  habits, 
and  will  forget  all  his  training.  After  that  he  will  be  for  a 
day  or  two  irritable,  violent,  impulsive,  and  even  dangerous. 
He  articulates  in  a  clnldish  way.  He  is  getting  worse,  and 
will  no  doubt  die  some  day  in  a  fit  or  after  a  series  of  fits. 
I  have  seen  the  steady  use  of  the  bromide  of  potassium  very 
useful  in  such  cases,  lessening  the  number  of  the  fits  and 
their  severity,  diminisMng  the  irritabOity,  and  improviag  the 
nutrition.  We  have  one  boy  here  who  is  quite  another  beiag 
for  the  past  four  years  under  20-grain  doses  three  times  a 
day. 

The  paralytic  form  of  idiocy  is  represented  by  this  case  of 
E.  G.,  who  was  normal  in  body  and  miad  till  he  was  four 
years  of  age.  He  then  had  an  apoplectic  attack,  and  his  left 
hand,  arm,  leg,  and  left  side  of  his  face  and  head  have  been 
partially  paralysed,  ill-developed,  and  the  Hmbs  shrunken,  con- 
tracted, and  useless  ever  siace.  He  takes  sporadic  epileptic 
attacks.  He  tries  to  articulate,  but  you  cannot  make  out 
what  he  says;  he  is  restless,  irritable,  not  very  educable, 
weak,  and  cold.  Such  cases,  looked  at  from  the  motor  point 
of  view  by  the  general  physicians,  constitute  one  variety  of 
essential  paralysis  of  infancy.  The  degree  to  which  the 
paralysis  and  the  mental  affection  are  found  in  different  cases 
varies  from  sanity  to  idiocy,  from  the  shghtest  weakness  to 


.      STATES   OF   MENTAL   ENFEEBLEMENT.  301 

complete  paralysis,  shrivelling,  and  contortion  of  the  limbs. 
The  pathology  of  those  cases  is  very  interesting.  Often  the 
convolutions  in  the  affected  hemisphere  are  found  undevel- 
oped, damaged,  or  atrophied,  the  lower  gangha  and  centres 
undeveloped,  and  one-half  of  the  spinal  cord,  as  well  as  the 
motor  nerves  from  it  to  the  affected  side,  atrophied  or  not 
developed.  In  some  cases  we  find  the  bones  of  the  cranium 
enormously  thickened  compensatorily  on  the  affected  side  (as 
we  found  in  E.  G.'s  case  when  he  died).  I  have  never  been 
able  to  understand  why  cerebral  apoplexies  occur  in  infancy. 
I  am  inchned  to  think  that  they  are  often,  not  effusions  of 
blood,  primarily  at  least,  but  vaso-motor  spasms  with  subse- 
quent dilatations  affecting  certain  of  the  cerebral  vessels,  and 
resulting  in  trophic  damage  to  the  parts  of  the  brain  affected. 
We  may  have,  however,  apoplexies  in  childhood  and  succeed- 
ing paresis  without  marked  mental  defect. 

Inflammatory  idiocy  results  from  the  inflammations  and 
sloughings  that  affect  the  throat  and  ears  in  scarlet  fever, 
spreading  inwards  and  damaging  the  brain.  Certain  portions 
of  the  organ  are  sometimes  found  to  be  hypeTtrophic  in  those 
cases.     It  is  a  very  unfavourable  variety. 

Traumatic  idiocy  is  much  like  the  inflammatory,  or  some- 
times like  the  paralytic  form,  and  results  from  falls  and  blows 
on  the  head. 

The  microcephalic  is  a  very  interesting  variety  of  idiocy.  On 
the  whole,  the  heads  of  idiots  are  smaller  than  those  of  sane 
persons,  but  there  are  many  exceptions  to  this  rule,  and,  as  a 
matter  of  fact,  the  average  sizes  of  the  heads  of  idiots  are  as 
large  as  the  minimum  sizes  of  perfectly  sane  persons.  Ireland 
says  : — "  The  size  of  the  head  gives  no  estimate  of  the  compara- 
tive intelligence  of  the  (idiotic)  children."  There  is,  however, 
a  certain  minimum  size  below  which  a  head  is  incompatible 
with  average  intelligence.  I  believe  a  circumference  of  below 
18  inches  means  idiocy.  Very  typical  microcephalics  are  rare, 
but,  when  seen,  they  make  a  strong  impression.  "With  their 
bird-hke  profiles  they  look  so  impish  and  unearthly.     They 


302  STATES   OF   MENTAL   ENFEEBLEMENT. 

are  usually  active,  alert,  mischievous,  imitative,  intractable, 
I  have  no  really  good  specimen,  but  E.  H.,  with  a  head 
of  18  inches  in  circumference,  a  small  face,  a  small  but 
perfectly  well-formed  body,  an  active,  imitative  way,  and  a 
restless  manner,  gives  an  idea  of  one.  Her  only  deformity  is 
a  cleft  and  acutely  arched  deformed  palate.  She  just  looks 
like  a  little  dried-up  woman,  with  small  features  and  a  singular 
expression  of  face,  and  she  smiles  as  if  a  baby  was  imitating 
the  features  of  an  old  woman,  Microcephahcs  should  always 
be  sent  to  training-schools.  They  are  often  educable  up  to 
a  certain  point,  and,  if  not  educated  and  employed,  they 
are  often  little  demons.  Their  musciilar  activity,  therefore, 
must  be  provided  with  outlets, 

Hydroceijlialic  idiocy  is  very  common,  but  I  need  hardly 
say  to  you  that  hydrocephalus,  with  even  enormous  enlarge- 
ment and  great  deformity  of  the  head,  is  perfectly  compatible 
with  sanity  and  mental  capacity.  It  usually  has  a  dwarfing 
and  often  a  deforming  effect  on  the  body.  A  small  head  is 
no  proof  that  there  has  not  been  hydrocephalus. 

E.  I.  is  a  good  example  of  a  hydrocephahc  idiot.  She  is 
now  ten,  and  is  slow  in  her  movements,  very  gentle  and 
patient ;  sometimes  cries  and  moans,  as  if  she  had  an  organic 
sensation  of  discomfort  in  her  head.  Her  head  is  globular, 
the  fontaneUes  raised,  the  temples  projected.  She  looks 
unhealthy,  has  scrofulous  glands  and  a  feeble  constitution. 
Her  temper  is  good.  She  is  educable,  and  worth  educating, 
I  am  going  to  have  her  sent  from  this  to  an  imbecUe  training 
institution,  Drs  Batty  Tuke  and  Campbell  Clark  have  de- 
scribed very  fully  the  condition  of  the  brain  in  certain  cases 
of  hydrocephalic  idiocy.  The  former  found  enormous  hyper- 
trophy of  the  neurogha,  and  the  latter  found  a  floating  lobe 
or  portion  of  brain  unattached  to  any  other  nerve  tissue, 
which  could  never  therefore  have  exercised  nerve  functions, 
yet  it  had  nerve  cells  and  fibres  in  a  primitive  form. 

Idiocy,  real  or  apparent,  may  occur  by  deprivation  of  the 
senses  only.     The  famous  case  of  Laura  Bridgman,  who  was 


STATES   OF   MENTAL   ENFEEBLEMENT.  303 

blind,  deaf,  and  dumb,  and  with  an  indistinct  sense  of  smell, 
but  with  common  sensation  through  which  Dr  Howe  educated 
her  brain,  developed  intelligence  and  emotion,  and  raised  her 
from  a  condition  of  absolute  want  of  intelligence  to  one  of 
great  mental  capacity,  is  and  will  always  be  the  classical  case 
of  apparent  idiocy  by  deprivation.  She  differed  essentially 
from  most  other  forms  and  cases  of  idiocy  in  having  a  brain 
well  developed  and  apparently  normal  in  all  respects,  except 
that  its  inlets  and  outlets  were  obstructed.  Ordinary  deaf- 
mutism  is  closely  allied  to  idiocy,  and  is  one  of  the  hereditary 
neuroses.  Insanity  is  very  much  more  common  among  deaf- 
mutes  than  among  the  general  population.  To  me  i-t  seems  a 
physiological  sin  that  marriages  between  such  persons  should 
be  legal,  though  apparently  healthy  progeny  often  results. 
Eut  we  know  that  each  one  of  these  must  carry  potential 
neuroses  to  future  generations. 

Cretinism  is  an  endemic  disease  occurring  in  connection 
with  goitre  in  some  valleys  of  mountain  chains,  such  as  the 
Alps,  Cordilleras,  and  Himalayas,  and  is  very  seldom  found 
here,  so  I  need  say  nothing  about  it.  It  is  very  interesting 
from  an  etiological  and  pathological  point  of  view,  and  has 
quite  a  Hterature  of  its  own  on  the  Continent, 


LECTUEE  VIII. 

STATES  OF  MENTAL  STUPOR  ("ACUTE  DE- 
MENTIA," "PEIMARY  DEMENTIA,"  "DE- 
MENTIA   ATTONITA,"    PSTGHOCOMA).      ' 

A  distinct  variety  of  mental  disease — Definition :  Lethargy  ;  stupor  ; 
impressions  on  senses  produce  no  effect ;  attention  gone  ;  desire  and 
emotion  absent ;  stupor  from  the  physiological  point  of  view ;  re- 
ceptivity and  irritability  of  brain  gone  ;  higher  reflex  functions 
suspended  ;  even  reflex  functions  of  cord  lessened  ;  hunger  and  thirst 
not  felt;  reproductive  instincts  not  absent,  but  they  assume  de- 
praved automatic  forms — Age  commonly  between  20  and  30  ;  mental 
condition  may  be  unconscious,  conscious,  or  half  conscious  ;  mus- 
cular system  may  be  passive,  cataleptic,  or  resistive — Melancholic 
Stupor  {Melancholia  Attonita,  Melancholie  avec  Sttcpew) :  An 
intense  melancholia,  with  delusions  that  "paralyse"  the  mind; 
memory,  consciousness,  and  attention  not  gone  ;  sensibility  not 
gone;  prognosis;  54  per  cent,  recover — Anergic  Stupor  ("Acute 
Dementia,"  "Primary  Dementia,"  "Dementia  attonita"):  A  real 
stupor ;  sensibility,  memory,  attention,  resistance  gone ;  feeble 
circulation  ;  vaso-motor  paralysis  ;  relationship  of  stupor  to  trance, 
hypnotism,  and  catalepsy.  Pathology — Treatment:  Vaso-motor 
stimulants;  continued  current ;  strychnine;  iron;  ergot ;  warmth ; 
rubbing ;  shower  baths.  Moral  treatment  unavailing  at  first. 
Causation:  1.  Sexual;  2.  Emotional  shock;  3.  Acute  disease;  4. 
Alcoholism  ;  5.  A  stage  of  other  mental  diseases  ;  6.  Senility — 
Secondary  Stupor :  Transitory  ;  sequential,  usually  following  sharp 
attacks  of  acute  mania  ;  curable. 

You  wiU  not  find  stupor  put  among  the  ordinary  symptomato- 
logical  varieties  of  mental  diseases,  along  with  mania,  melan- 
cholia, &c.  This  I  think  is  a  mistake.  The  only  objections  to 
its  being  so  placed  are  two, — that  it  is  not  commonly  a  primary 
disease,  and  that  the  word  stupor  does  not  imply  to  the  lay  or 
even  to  the  medical  mind  any  necessary  mental  disease  at  all. 


STATES   OF   MENTAL   STUPOK.  305 

as  tliey  understand  it.  But  these  objections  should  not  prevent 
us  using  the  word  to  express  in  a  correct  scientific  sense  a 
morbid  mental  condition,  which  is  different  psychologically  and 
cKnically  from  all  other  morbid  mental  conditions  which,  while 
it  lasts,  demands  different  treatment  from  them  in  many  cases, 
and  has  a  different  course  and  termination.  Stupor,  used  in 
this  strict  medico-psychological  sense,  may  be  thus  defined  : — 
"  A  morbid  condition  in  which  there  is  mental  and  nervous 
lethargy  and  torpor,  in  which  impressions  on  the  senses  pro- 
duce little  or  no  outward  present  effect,  in  which  the  faculty 
of  attention  is  or  seems  paralysed,  in  which  there  is  no  sign  of 
originating  mental  power,  in  which  the  higher  reflex  functions 
of  the  brain  are  paralysed,  and  in  which  the  voluntary  motions 
are  almost  suspended  for  want  of  convolutional  stimulus,  but 
where  the  patients  usually  retain  the  power  of  standing,  walk- 
ing, masticating,  and  swallowing." 

The  condition  of  stupor  may  be  the  expression  of  an  ex- 
hausted, lo\yered,  and  devitalised  brain. 

A  typical  case  of  this  condition  stands  for  hours  where  he  is 
placed,  in  the  same  attitude  ;  when  spoken  to  he  takes  no  notice  ; 
he  shows  no  active  desires,  passions,  or  affections ;  he  does 
not  speak  nor  move,  nor  show  any  interest  in  anything.  His 
expression  of  face  is  vacuous  ;  his  vaso-motor  power  is  much 
below  normal,  so  that  liis  extremities  look  blue  and  are  cold ; 
he  does  not  obey  the  calls  of  nature,  nor  take  any  notice  of  them 
at  all.  Loud  sounds  make  no  impression ;  pleasant  or  terrible 
sights  that  would  in  others  produce  motion  and  emotion  fail  to 
do  so.  A  woman  once  committed  suicide  by  hanging  herself  in 
a  dormitory  at  Morningside  in  the  presence  of  another  patient 
in  a  condition  of  stupor,  who  took  no  notice  whatever  of  tliis 
frightful  sight. 

Looking  at  the  condition  of  stupor  from  the  point  of  view  of 
the  physiology  of  the  brain,  we  see  that  its  power  of  receiving 
impressions  from  without  is  in  abeyance,  and  its  higher  reflex 
functions  suspended.  The  mental  and  motor  irritation  of  a  full 
bladder  or  loaded  rectum  is  not  felt  by  the  higher  brain  centres  ; 

U 


306  STATES   OF  MENTAL   STUPOR. 

and.  when,  through,  the  action  of  the  lower  centres,  evacuations 
take  place,  there  is  either  no  consciousness  of  them  on  the  part 
of  the  highest  centres,  or,  if  there  is,  it  does  not  result  in  the 
vohtion  that  prepares  suitably  for  them,  or  in  the  vexation 
that  would  be  felt  in  health  if  they  took  place  over  the  body. 
Even  the  ordinary  skin  and  spinal  reflexes  are  much  diminished 
or  abohshed.  The  appetites  for  food  and  drink  are  paralysed, 
or,  if  felt,  are  not  followed  by  any  exertion  to  satisfy  them. 

Age,  and  Relationship)  to  Reproduction,  Hysteria,  Mastur- 
bation, &c. — Most  of  the  typical  cases  of  stupor  occur  in  the 
actively  reproductive  period  of  life.  The  majority  of  them,  in 
fact,  are  under  30.  Dr  Hack  Tuke^  found  that  27  .was  the 
average  age  in  20  cases.  In  my  experience  all  the  very  typical 
cases  are  nearer  20  than  30.  A  striking  exception,  and  the 
only  material  exception,  to  the  passivity  or  suspension  of  brain 
function  in  stupor,  is  the  gratification  of  the  reproductive 
instinct  in  a  low  automatic  form,  the  inhibitory  centres  being 
dormant.  In  the  majority  of  the  cases  the  commencement  of 
the  disease  had  been  connected  with  or  accompanied  by  a  sexual 
excitation  in  some  form  or  other.  Many  of  them  had  indulged 
badly  in  masturbation  and  had  exhausted  the  brain  energy 
thereby — had  "stupefied"  themselves  in  fact  by  this.  Most 
of  them  indulged  in  this  habit  long  after  they  had  entered  into 
a  condition  of  mental  stupor,  doing  it  automatically  rather 
than  volitionally,  and  many  of  them  have  sexual  delusions  at 
the  expiry  of  the  attack. 

jNIany  of  the  girls  had  been  hysterical,  and  showed  during 
their  disease  marked  hysterical  symptoms.  The  aspect, 
expression  of  eyes,  and  behaviour  before  the  other  sex,  while 
consciousness  existed,  were  markedly  erotic,  this  being  so  in 
some  of  the  cases  even  after  speech  and  all  outward  mental 
manifestations  had  ceased.  Many  of  them  have  cataleptic, 
trance,  and  hystero-epileptic  symptoms,  all  these  affections 
being  commonly  connected  with  the  function  of  reproduction, 
its  disorders,  or  its  perversions.  The  direct  connection  of 
^  International  Medical  Congress,  1881.  Transactions,  vol.  iii.  p.  638. 


STATES   OF  MENTAL   STUPOK.  307 

stupor  in  most  cases  with  the  reproductive  and  sexual 
functions  has  not  heen  sufficiently  considered  hitherto. 
Those  functions  are  the  dominant  vital  activities  from 
adolescence  to  35  in  many  persons  of  the  neurotic  diathesis. 
If  the  inherent  hrain  stability  is  hereditarily  weak,  with  the 
inhibitory  power  poorly  developed,  and  if  under  those  cir- 
cumstances there  is  intense  sexual  excitabihty  or  a  constant 
sexual  drain  through  masturbation  or  excessive  sexual  inter- 
course, then  is  stupor,  in  some  form  or  degree,  the  natural 
expression  of  the  exhaustion  of  the  higher  nerve  force  that 
follows.     We  shall  see  examples  to  prove  this  presently. 

When  I  thus  bring  out  strongly  the  connection  of  stupor 
with  the  reproductive  function,  it  must  be  remembered  that 
I  am  referring  particularly  to  that  form  which  is  attended  by 
unconsciousness,  though  tliis  may  have  a  distinctly  melan- 
chohc  stage  or  tinge  throughout — mental  depression,  too,  being 
a  symptom  of  brain  exhaustion — and  it  must  be  kept  in  mind 
that  there  are  individual  cases  of  stupor  of  the  melancholic 
type  at  all  ages  and  resulting  from  other  causes,  such  as 
mental  or  nervous  shocks,  frights,  losses,  or  bodily  diseases, 
which  have  no  reproductive  or  sexual  compHcation  at  all. 

Muscular  Conditions. — The  voluntary  motor  system  is  found 
to  be  in  three  conditions  in  different  cases  or  in  different  stages 
of  the  same  case,  viz.,  (1)  passive,  unresistive,  and  having  no 
tendency  to  keep  fixed  positions ;  (2)  cataleptic,  with  decided 
tendencies  to  keep  fixed  attitudes  and  positions,  but  with  no 
resistance  to  external  force  used  in  changing  the  "waxy" 
muscular  conditions;  (3)  resistive,  showing  a  more  or  less 
strong  resistance  to  external  efforts  to  change  the  position. 
The  first  is  commonly  found  in  the  anergic  form  of  stupor, 
especially  when  it  is  caused  by  a  previous  acute  attack  or  by 
masturbation ;  the  second  also  in  some  of  the  anergic  re- 
productive cases ;  and  the  last  in  the  melanchoHc  form  alone. 
Varieties. — Looked  at  from  the  'purely  mental  poini  of  view, 
conditions  of  stupor  are  divisible  into  three  varieties,  viz.,  the 
unconscious — the  anergic, — where  consciousness  and  memory 


308  STATES   OF   MENTAL   STUPOR. 

are  gone;  the  conscious — the  inelanclioUc, — where  they  are 
both  present,  and  where  there  is  a  delusion  present,  these  facts 
being  ascertained  and  tested  afterwards  by  the  patient's  own 
account;  and  the  half-conscious,  or  confused,  where  there  is 
some  consciousness,  but  by  no  means  a  keen  or  a  correct 
subjective  reahsation  of  events,  and  where  the  recollection  of 
them  afterwards  is  confused  or  delusional.  Some  cases  pass 
through  all  these  conditions  in  diflTerent  stages.  Conditions  of 
mental  stupor  have  excited  much  mterest,  and  have  an  exten- 
sive literature,  especially  in  France.  Dr  Hayes  Newington, 
when  assistant  physician  in  Morningside  in  1874,  studied  them 
carefully,  and  wrote  a  capital  description^  of  them,  with  which 
I  in  the  main  agree ;  indeed,  all  must  agree  with  him,  for 
he  sticks  closely  to  clinical  fact.  He  gave  us  the  admirable 
word  "anergic"  to  describe  the  passive,  unconscious,  non- 
depressed  cases.  This  should  take  the  place  of  the  older  term 
"acute"  or  "primary"  dementia,  still  commonly  apphed  to 
such  cases,  which  should  be  discontinued,  for  it  is  confusing 
and  incorrect.  If  you  take  a  typical,  case  of  either  the 
melanchoUc  or  the  anergic  varieties,  each  undoubtedly 
corresponds  to  his  descriptions ;  but  an  extended  clinical 
experience  has  shown  me  that  the  same  case  may  begin  by 
being  in  the  condition  of  melanchohc  and  conscious  stupor, 
and  may  end  by  passing  into  the  anergic  and-  unconscious 
variety.  Then  I  find  that  by  far  the  greater  number  of 
the  cases  that  were  anergic  during  the  greater  part  of  their 
course  had  a  short  melanchohc  stage  to  begin  with.  As  for 
stupor  being  a  primary  affection,  I  call  to  mind  very  few  cases 
where  it  was  entu'ely  so.  Insanity  seldom  begins  with  stupor. 
There  is  a  stage  of  mental  depression  or  of  mania, — very 
short,  it  may  be,  but  still,  present.  The  stupor  may  be 
the  disease  for  all  practical  and  clinical  purposes,  but  preceded 
by  an  initiatory  stage  of  another  condition.  The  cases  wliich 
Ave  shall  see,  or  to  which  I  shall  refer,  will  illustrate  those 
various  points  of  causation  and  symptoms. 

1  Journal  of  Mental  Science,  October  1874. 


STATES  OF  MENTAL   STUPOE.  309 

The  best  clinical  division  of  stupor  would  be,  I  think,  into 
the  following  kinds ;  which,  in  the  order  of  their  frequency 
or  importance,  are  :' — 

a.  Melancholic  stupor. 

&.  Anergic  stupor. 

c.  Secondary    stupor    (transitory    after     acute    mental 

disease). 

d.  General  paralytic  stupor. 
.  e.  Epileptic  stupor. 

Melancholic  Stupor  is  the  most  frequent  form.  It  is  the 
melancholia  attonita,  or  the  melancholie  avec  stupeur,  of  the 
authors.  As  I  have  said,  it  is,  either  throughout  its  whole 
course  or  at  some  part  of  it,  the  conscious  and  delusional 
form  or  the  half-conscious  looked  at  from  the  mental  point 
of  view,  the  resistive  looked  at  from  the  muscular  aspectj 
and  the  less  paralytic  looked  at  from  the  vaso-motor  point 
of  view.  Some  authors  write  as  if  there  was  always  one 
overmastering  delusion  of  a  terrible  kind, — the  patient 
fancying  himself  dead,  or  that  he  is  too  Avicked  to  hold 
intercourse  with  liis  fellow-men,  or  that  if  he  speaks  he  will 
be  killed,  &c.,  which,  as  it  were,  fills  the  whole  mental 
vision  and  leaves  no  room  for  any  other  manifestation  of 
mind,  paralysing  speech,  and  active  volition  of  any  kind. 
I  do  not  think  this  a  true  view  to  take.  There  may  or 
there  may  not  be  such  a  delusion,  but  by  itself  a  delusion 
never  causes  stupor.  There  must  be  something  more  than 
this.  There  is  always,  in  addition,  a  distinct  morbid  con- 
dition of  the  brain  affecting  its  reflex  action,  its  trophic  and 
vaso-motor  state,  its  receptive  power  in  all  directions,  and 
most  especially  its  active  ideo-motor  functions.  !N"one  of  these 
things  are  the  necessary  concomitants  of  merely  delusional 
conditions.  I  look  on  the  delusion  as  one  symptom  only, 
and  not  the  cause  of  the  melancholic  stupor.  Melancholic 
cases  are  sometimes  suddenly  impulsive  at  one  period  of  the 
disease,  and  it  is  well  to  remember  that  during  convalescence 
they  may  be   suicidally  impulsive.     Gusts  of   motor  energy 


310  STATES    OF   MENTAL   STUPOR. 

seem  suddenly  to  be  evolved  in  tlie  brain,  and  in  fact  I  look 
on  those  as  being  correlative  and  complementary  to  stuporose 
conditions.  I  have  seen  epileptiform  fits  occur  occasionally 
in  such  cases,  but  much  more  frequently  a  condition  merely 
simulating  epilepsy  or  apoplexy,  the  patient  being  conscious 
and  having  a  real  control  over  the  muscular  movements. 
Wlienever  you  see  a  melanchoHc  patient  said  to  be  "in  a 
fit,"  always  think  of  this  condition.  It  is  not  uncommon. 
In  some  instances  this  state  occurs  as  the  acme  of  an  ordinary 
case  of  delusional  or  excited  melancholia,  being  a  short 
incident  in  the  case.  In  other  instances,  though  preceded 
by  depression  of  mind,  the  stiipor  is  the  chief  part  of  the 
disease.  In  some  instances  the  stupor  remains  characteris- 
tically melanchohc  all  through — being  conscious,  resistive, 
and  unaccompanied  by  much  vaso-motor  paralysis.  In  other 
instances  it  passes  into  anergic  stupor, — the  patient  becoming 
unconscious,  unresistive,  and  with  marked  vaso-motor  and 
trophic  paresis.  Some  cases  of  melanchohc  stupor  assume 
melancholic  attitudes.  Here  is  a  young  woman  who  lies 
flat  on  the  ground,  with  her  face  on  the  floor,  and  she  resists 
being  placed  on  a  chair.  Here  is  a  young  man  who  is  bent 
down  till  he  almost  crouches.  Here  is  another  who  puts  his 
fingers  to  his  ears  and  keeps  them  there. 

The  follo'wing  are  three  cases  of  melancholic  stupor,  the  first 
tivo  {E.  M.  and  E.  N.)  heing  patients  of  the  ordinary  type, 
and  the  third  (E.  0.)  being  a  very  extraordinary  case  in  its 
severity,  duration,  and  the  length  of  time  he  ivas  artificially  fed, 
and  in  its  terminatio^i  in  recovery  in  these  circumstances  : — 

E.  M.,  set.  21,  a  weU-educated,  bright,  clever,  and  industri- 
ous youth  of  sanguine  temperament.  No  nervous  heredity 
admitted.  Habits  temperate  and  correct.  The  cause  of  the 
attack  was  over-study  when  he  was  rapidly  developing  in 
body,  and  had  not  attained  manhood.  His  brain  was. ex- 
hausted by  the  body  growth,  development,  want  of  sleep,  and 
continuous  mental  efi'ort.  His  first  symptoms  began  eighteen 
months  ago,  and  were  mental  depression,  sleeplessness,  and 


STATES   OF   MENTAL   STUPOE.  311 

pain  in  the  head.  He  got  worse  in  mind  and  body,  and  soon 
"became  suicidal — attempting  to  take  away  his  Ufe.  He 
became  suspicious,  too,  his  affection  for  his  relations  diminish- 
ing, and  he  "was  fickle.  He  then  got  so  much  better  through 
rest  and  change  that  he  resumed  his  work  and  studies. 
When  he  relapsed,  a  few  weeks  before  admission,  he  became 
again  very  suicidal — asking  for  poison,  and  wanting  to  drown 
himself.  His  motive  for  suicide  was  that  people  were  going 
to  kiU  him.  On  admission  he  was  much  depressed,  though  he 
could  pick  himself  up  and  smile  in  a  forced  way.  He  was 
very  fearful,  imagining  that  he  had  done  some  great  crime, 
and  that  he  was  to  be  tried  and  would  be  hanged.  He  was 
thin,  his  muscles  flabby,  his  pulse  60  and  weak,  bowels  consti- 
pated. Temperature — 97'2°  in  the  morning,  96*4°  at  night. 
Weight,  9  st.  10  lbs.  He  was  unsettled  and  restless  at  night 
as  well  as  being  sleepless.  His  appetite  was  poor.  He  was 
evidently  all  the  time  looking  for  the  means  of  suicide,  so  he 
was  carefuUy  watched  night  and  day.  He  got  more  confused 
and  more  obstinate,  until  in  a  fortnight  after  his  admission 
he  was  in  a  state  of  complete  stupor ;  his  countenance  wore  a 
heavy,  semi- vacuous,  depressed  expression;  he  would  not 
answer  questions  nor  take  notice  of  anything ;  was  utterly 
careless  of  his  dress  and  person,  letting  his  motions  pass  where 
he  stood.  The  skin  had  a  warm,  clammy  feel,  except  at  the 
extremities,  which  were  blue  and  cold.  He  had  a  few  lucid 
intervals  of  a  few  minutes  each,  when  he  would  as  it  were 
wake  up  and  ask  where  he  was.  The  treatment  from  the 
beginning  consisted  of  his  being  compelled  to  take  an  enor- 
mous quantity  of  milk  and  eggs  in  liquid  custards,  flavoured 
with  nutmeg,  and  with  half  a  glass  of  sherry  in  each.  He 
took  usually  in  the  day  12  eggs  and  6  pints  of  milk,  and 
began  to  gain  in  weight  after  the  first  fortnight.  He  had 
quinine  and  strychnine  in  moderate  doses,  and  cod-Hver  oil 
emulsion,  containing  hypophosphite  of  lime  and  pepsine.  He 
was  walked  in  the  open  air  a  great  deal.  His  skin  was  well 
rubbed  with  rough  towels  night  and  morning,  and  occasionally 


312  STATES   OF   MENTAL  STUPOR. 

he  had  the  continued  current  up  to  fifteen  cells.  He  steadily 
gained  in  weight.  .After  three  months'  treatment  he  began 
to  speak,  and  wrote  the  following  letter  to  his  mother  : — "My 
mother,  please  let  me  go  home.  I  don't  know  where  I  am. 
I  feel  very  ill.  "Would  you  let  me  go  home."  In  a  few  days 
he  wrote  to  her  to  send  him  some  money  to  pay  for  his  main- 
tenance here,  saying  that  he  thought  about  £3000  would  do, 
that  he  was  a  nuisance  to  those  around  him,  and  asking  what 
great  crime  he  had  committed,  and  requesting  that  he  might 
be  punished  adequately.  In  another  month  the  confusion  of 
mind  was  passing  away  ;  in  a  month  from  that  he  was  prac- 
tically well  in  reasoning  power,  in  feehng,  memory,  and 
in  bodily  health,  and  was  over  11  stone  in  weight,  having 
gained  18  lbs.  He  was  bright,  inteUigent,  lively,  and  a  great 
favourite.  He  said  he  remembered  in  a  confused  way  the 
events  that  occurred  during  his  period  of  stupor,  that  he  had 
the  delusion  all  the  time  he  had  committed  a  crime,  and  was 
to  be  punished,  and  could  not  pay  for  the  food  given  to  him. 
"When  discharged,  six  months  after  admission,  I  never  was 
inore  satisfied  in  any  case  that  a  complete  recovery  had  been 
made.  I  always  like  to  see  a  patient  get  fat  on  recovery  from 
any  form  of  insanity. 

This  was  a  very  typical  case  of  melancholic  stupor,  and 
would  be  called  by  most  authors  one  of  "primary  dementia," 
showing  well  how  the  stupor  was  the  acme  of  the  brain 
condition,  which  showed  itself  first  as  melanchoha,  how 
there  was  a  melanchohc  tinge  through  the  stupor,  and  a 
distinct  melanchohc  delusion.  But  I  conceive  it  would  be  a 
mistake  to  describe  the  stupor  as  being  caused  by  this  profound 
delusion.  As  a  matter  of  fact,  in  tliis,  as  in  all  such  cases, 
the  intensity  of  reahsation  of  the  delusion,  and  the  capacity 
to  feel  keenly,  were  blunted  by  the  condition  of  stupor.  The 
stupor  I  look  on  as  a  brain  condition  distinct  from  that  of 
acutely  felt  depression  in  melanchoha,  in  which  delusions  are 
vivid  and  the  misery  acute.  "We  find  that  delusions  alone 
never   cause   stupor,  whatever   their   character.     They   may 


STATES   OF   MENTAL   STUPOR.  313 

cause  prolonged  taciturnity  for  years,  but  this  is  totally 
different  from  stupor.  The  condition  of  the  mental  portion 
of  the  convolutions  in  stupor  is  probably  analogous  to  the 
stupidity  of  a  nervous  child  when  terrified  or  bulhed. 

The  following  was  a  case  of  melancholic  stupor  of  short  dura- 
tion, and  tvith  a  complete  recovery  : — 

E.  IS".,  aet.  35.  Temperament  melanchoHc.  Habits  intem- 
perate ;  a  prostitute.  Heredity — mother  intemperate,  and 
subject  to  periodic  attacks  of  melanchoha.  Her  illness  began 
by  melancholic  depressions  "and  delusions,  but  .she  soon  became 
excited,  noisy,  and  tried  to  commit  suicide.  She  had  no  great 
overmastering  melancholic  delusion  to  account  for  the  stupor 
into  which  she  soon  passed  after  admission,  wliich  was 
complete,  with  all  the  characters  of  melanchoHc  stupor,  being 
muscularly  resistive  with  no  cataleptic  tendency,  with  refusal 
of  food,  and  expression  of  face  depressed.  She  would  not 
walk  nor  move,  and  had  to  be  kept  in  bed.  .  She  remained  in 
that  state  for  about  six  weeks.  It  was  evidently  the  acme  of 
the  attack  of  melanchoha,  and  she  shortly  got  better  and  made 
a  good  recovery  in  six  months.  She  said  that  the  period  of 
stupor  was  a  blank  to  her,  and  she  remembers  notliing  that 
took  place  then. 

The  following  was  an  extraordinary  case  of  prolonged 
melancholic  delusional  stupor,  lasting  three  years,  and  requiring 
artificial  feeding  all  that  time,  with  final  recovery. 

F.  0.,  set.  31.  Admitted  26th  January  1876.  Disposition 
retiring.  Strumous  diathesis.  Habits  unsocial,  and  almost 
too  industrious  and  sedentary.  Excessive  masturbation. 
Eather  intemperate ;  mother  died  of  consumption.  Had  one 
slight  attack  of  mental  disease — melanchoha — three  years  ago, 
from  which  he  quite  recovered  in  a  few  months.  First  symp- 
toms of  mental  disease  were  shght  depression  and  foolish 
fancies.  Along  with  these  there  were  sleeplessness,  pains  in 
head,  loss  of  nutrition,  and  great  coldness  of  extremities. 
Sometimes  he  could  not  be  kept  warm  by  any  means  used. 
Was  not  dirty,  destructive,  nor  obscene,  nor  violent.    Those 


314  STATES  OF   MENTAL   STUPOR. 

symptoms  showed  themselves  fifteen  months  ago.  As  he  got 
worse  he  opened  a  vein  and  lost  some  blood,  and  on  several 
other  occasions  he  seemed  to  have  tried  to  choke  himself  with 
a  scarf.  He  was  at  times  noisy  and  incoherent,  and  sleepless. 
He  had  changing  delusions,  e.g.,  that  his  brain  was  compressed 
by  an  evil  spirit. 

On  admission  he  was  'depressed  and  hypochondriacal,  fancy- 
ing that  he  was  dangerously  ill,  that  he  had  been  a  great 
sinner  and  very  hcentious,  that  he  suffered  shame  more  than 
all  mankind,  and  that  his  body  had  been  tampered  with  when 
he  had  attempted  suicide.  Along  with  the  depression  there 
was  much  mental  enfeeblement,  facihty,  childishness,  and 
impairment  of  memory,  with  rambling  and  incoherence.  He 
had  delusions  about  his  sexual  organs.  He  was  anaemic, 
flabby,  thin,  and  we  thought  that  there  was  shght  comparative 
dulness  at  apex  of  right  lung,  with  rough  breathing  sounds. 
Temperature,  98'4°.  Height,  5  feet  6|^  inches.  "Weight,  8  st. 
13  lbs. 

He  remained  very  much  in  this  mildly  melanchohc  condition 
for  three  months.  He  constantly  wanted  quack  medicines, 
had  a  poor  appetite,  and  used  to  twist  and  wriggle  his  body 
about  in  obedience  to  delusions.  He  then  had  an  attack  of 
deeper  depression,  "with  more  confirmed  delusions,  intense 
insane  obstinacy,  impulsive  violence,  shouting  at  times  and 
twisting  his  body  about,  as  if  there  were  beasts  crawling  on 
him.  After  this  he  refused  food  entirely  in  May,  and  was  fed 
with  the  stomach  pump  on  May  7,  1876,  resisting  strongly. 
He  took  his  food  on  the  17th,  but  again  needed  to  be  fed  on 
the  18th,  and  for  several  weeks  afterwards.  Then  for  several 
months  he  took  his  food  himself,  his  mental  condition  other- 
wise remaining  much  as  before,  and  his  delusions  being  very 
pronounced.  But  in  May  1877  he  again  began  to  refuse  food, 
and  from  that  time  till  April  30,  1880 — a  period  of  over  two 
years  and  eleven  months — he  took  no  food,  and  required  to  be 
fed  twice  a  day  with  the  stomach  pump. 

But  this  was  not  the  most  extraordinary  part  of  his  case. 


STATES  OF  MENTAL   STUPOK.  315 

In  tlie  course  of  a  month  after  his  being  fed,  he  had  passed 
into  a  condition  of  absohite  stupor,  lying  motionless,  insensible 
to  pain,  unable  to  stand,  his  urine  and  faeces  dribbhng  away, 
his  circulation  feeble,  oflPering  no  resistance  to  anything  done 
to  him,  and  taking  no  notice  apparently  of  anything.  ^Notliing 
could  rouse  him,  nothing  could  stir  him,  nothing  could  excite 
any  mental  or  bodily  reply  or  response,  except  that  he  shut 
his  eyes  tightly  when  the  eyeballs  were  touched,  and  there  was 
shght  motion  of  the  legs  when  the  soles  of  his  feet  were  tickled. 
But  this  last  reflex  power  disappeared  in  October  1878.  Much 
difficulty  was  experienced  in  keeping  him  warm,  but  an  old 
and  most  affectionate  maiden  aunt,  who  came  to  s.ee  him  almost 
daily,  contrived  the  most  wonderful  woollen  foot  coverings 
and  body  rugs.  He  was  dressed  in  the  morning,  carried  down 
to  a  sofa,  and  his  penis  inserted  into  an  indiarubber  bottle, 
There  he  lay  all  day,  never  moving,  never  resisting  anything 
done  to  him.  He  seemed  the  most  complete  case  of  "acute 
dementia  "  or  anergic  stupor  I  ever  saw,  except  for  two  tilings  : 
these  were,  a  certain  expression  in  his  face,  which  was  never 
so  absolutely  blank  as  it  is  in  that  condition,  and  his  not  being 
able  to  stand  nor  move  at  all,  which  seldom  occurs.  There  was 
none  of  the  resistance  nor  muscular  rigidity  of  melancholic  stupor. 
As  regards  treatment,  he  was  fed  in  the  morning  with  a 
liquid  mess,  consisting  of  a  pound  of  beef  done  to  a  liquid  form 
in  a  large  mortar,  with  potatoes  and  vegetables  similarly 
pounded  down,  the  whole  being  made  Hquid  enough  to  pass 
readily  through  a  stomach-pump  tube  with  beef-tea  and  a 
quarter  of  a  pound  of  sugar.  In  the  evening  he  had  a  custard 
with  three  eggs  and  a  quarter  of  a  pound  of  sugar.  His  bowels 
kept  regular.  He  had  at  various  times  quinine,  strychnine, 
phosphorus,  ergot,  cod-liver  oil,  the  hypophospliites  of  lime 
and  iron,  and  the  continued  current  up  to  twenty  cells  of  a 
Hawksley's  battery,  used  once  a  day  for  months  together, 
through  his  brain  and  spinal  cord.  No  good  seemed  to  be 
done,  yet  he  was  a  case  about  whom  we  never  quite  lost  hope. 
His  nutrition  kept  fair,  and  he  did  not  lose  weight. 


316  STATES   OF   MENTAL   STUPOR. 

At  last,  in  June  1879,  he  was  observed  by  his  attendant  to 
turn  over  on  the  sofa.  Then  reflex  action  on  tickhng  of  the 
soles  returned,  and  his  countenance  began  to  acquire  more 
expression.  ■  The  continued  current  was  being  used  at  this 
time,  but  I  am  very  doubtful  if  it  had  anything  to  do  with  his 
improvement.  In  February  1880  his  glottis  became  more 
sensitive,  so  that  the  passage  of  the  tube  caused  coughing,  and 
he  raised  himself  up  after  feeding  once.  One  day  he  seized 
the  tube  and  remained  rigid  and  cataleptic  for  a  few  minutes. 
On  April  30,  1880,  he  spoke  for  the  first  time,  and  at  feeding 
time  said  he  was  tired  of  custards,  and  wanted  some  tea,  took 
a  moderate  tea  and  supper,  and  a  good  breakfast.  He  had 
never  lost  weight  during  all  the  time  of  his  artificial  feeding. 
He  took  no  food  on  May  1  st,  but  on  May  2nd  asked  Dr  Clark, 
who  was  about  to  feed  him,  if  it  was  the  custom  to  keep  sane 
men  in  the  Asylum,  and  on  being  told  that  it  was  not  much 
like  a  sane  man  to  refuse  food,  he  repHed,  "  Then  if  I  take  my 
food  wiU  that  prove  my  sanity  1 "  "  Yes,"  "  Then  give  it  me 
at  once."  He  took  it  there  and  then,  and  never  missed  a 
meal  afterwards.  He  was  weak,  and  his,  appetite  was  feeble 
at  first,  but  he  soon  began  to  walk,  then  to  go  out,  and  he 
got  stronger,  and  heavier  by  nearly  a  stone  than  he  was  on 
admission.  When  asked  about  his  stupor,  he  always  gave 
some  sexual  reason,  such  as  that  it  was  "gonorrhoea"  or 
"emissions  "  that  had  been  the  cause  of  it.  He  asserted  that 
he  had  been  conscious  all  the  time,  and  made  some  statements 
which  proved  that  there  had  been  some  consciousness,  reason- 
ing power,  and  memory.  He  described  how  a  sphygmograph 
was  used  on  his  radial  artery,  he  told  the  names  of  assistant 
physicians  who  had  been  in  charge  of  him  during  his  stupor, 
and  he  "asked  pardon  for  my  conduct."  His  memory  was 
not  quite  clear,  however ;  he  could  not  tell  much  about  what 
happened,  nor  the  year  he  entered  the  Asylum.  His  memory 
of  events  before  his  illness  was  good,  and  he  showed  much 
curiosity  as  to  what  had  been  going  on  in  the  religious  world. 
He  was  hypochondriacal,  notional,  and  somewhat  weak-minded. 


STATES   OF   MENTAL   STUPOK.  317 

and  was  discharged  relieved  on  June  21,  1880.  He  has  im- 
proved still  further  at  home,  his  old  maiden  aunt  thinking  liim 
as  well  as  ever  he  was  in  his  hfe,  and  considering  him  a  most 
intelhgent  and  exemplary  youth.  She  takes  almost  the  entire 
credit  of  his  resurrection,  a  distinction  which  I  am  much  in- 
chned  to  award  her,  for  she  kept  liim  warm,  she  kept  up  the 
interest  of  every  one  in  his  case  by  daily  visits,  and  she  never 
despaired  of  his  recovery. 

This  was  essentially  a  case  of  melancholic  stupor  {melan- 
cholia attonita,  pyschocoma,  melancholle  avec  stupeur),  with 
many  of  the  features  of  "  anergic  stupor."  In  fact,  after  the 
symptoms  attained  their  greatest  intensity,  when  there  was  no 
apparent  consciousness,  no  attention,  no  muscular  resistance, 
no  voluntary  motion,  no  spinal  reflex  function,  when  the 
body  temperature  was  very  low,  the  capillary  circulation  in. 
the  extremities  was  very  weak,  the  urine  and  faeces  passing 
involuntarily  and  at  aU  times,  I  considered  the  case  as  one  of 
anergic  stupor  (acute  dementia),  that  had  .arisen  at  first  out 
of  a  melancholic  condition,  and  used  to  speak  of  it  as  such,  a 
fact  of  which  the  patient  reminded  me  after  liis  recovery.  I 
certainly  did  not  think  there  was  consciousness,  or  attention, 
or  memory  really  present,  as  the  patient's  recollections  after- 
wards proved  them  to  have  been  to  some  extent.  In  old 
times  the  case  would  have  been  called  one  of  trance,  and  there 
were  many  of  the  features  of  what  is  now  described  in  the 
books  by  that  name.  Stupor  is  one  of  those  conditions  that 
seem  to  take  hold  of  the  popular  imagination,  cases  bemg 
reported  in  the  newspapers,  becoming  the  subject  of  works  of 
fiction,^  and  exciting  interest  in  all  sorts  of  ways.  The 
wonder  is  that  more  hysterical  young  women  don't  fall  into  it. 
The  way  in  which  it  is  sometimes  mismanaged  is  a  disgrace 
to  our  knowledge  of  mental  diseases.  Stupor  is  frequent  in 
hysteria.  I  think  it  probable  that  most  cases  of  trance,  if 
examined  by  an  alienist,  would  be  placed  under  melancholic 
or  anergic  stupor.  It  will  be  noted  how  well  the  digestive 
^  The  storj'  of  Called  Back  is  well  worth  reading. 


318  STATES   OF   MENTAL  STUPOE. 

and  trophic  functions  of  the  body  were  performed  when 
there  was  no  voluntary  muscular  action  whatever.  The 
great  length  of  time  during  which  the  symptoms  lasted,  and 
the  final  recovery,  so  far  as  the  stupor  was  concerned,  are 
very  marked  features  of  the  case,  if  they  are  not  unprece- 
dented. 

The  following  was  a  striking  case  of  stupor  {melancholic)  fol- 
lowing a  mental  shock : — 

E.  0.  A.,  get.  55,  of  a  melanchohc  temperament,  and  steady 
and  industrious  habits,  through  which  he  had  made  and  saved 
^6000.  There  was  no  known  neurotic  heredity.  He  was  a 
shareholder  in  the  City  of  Glasgow  Bank,  and  the  failure  of 
that  ill-fated  concern,  and  the  loss  of  all  his  money,  seemed 
to  "take  the  spirit  out  of  him."  completely.  He  became 
sleepless,  nervous,  and  much  depressed.  He  lost  weight — 
from  14  stone  to  10  stone  4  lbs.  He  first  spoke  constantly 
about  his  being  victimised  and  cheated,  and  then  expressed 
delusions  that  he  was  in  debt,  and  that  he  must  go  to  the 
pohce  office  and  give  himself  up.  His  delusions  next  referred 
to  his  body — no  doubt  his  organic  sensations,  as  he  got  thin, 
weak,  dyspeptic,  and  costive,  were  those  of  discomfort — and 
he  said  that  his  inside  was  burnt  up.  On  his  admission  to 
the  Asylum,  six  months  after  the  beginning  of  his  disease,  he 
was  with  difi&culty  got  to  speak,  to  answer  questions,  or  to 
take  food,  and  he  slept  badly.  He  would  appear  as  if  he 
were  about  to  speak  or  answer  a  question,  but  the  voHtion 
power  to  articulate  seemed  to  fail  him,  and  he  could  say 
nothing.  His  next  delusion  was  natural  enough,  the  wish 
being  father  to  the  thought.  He  fancied  he  was  dead,  and 
he  would  say — "  I  am  dead :  put  me  in  my  grave."  Then 
for  two  months  his  stupor  was  complete,  .with  no  outward 
expression  of  mentahsation  at  all.  But  the  expression  of  face 
was  melanchohc  as  well  as  stupid,  and  there  was  muscular 
resistance.  He  lay  in  bed  all  day.  All  this  time  he  was 
getting  weaker.  No  tonics  excited  liis  appetite,  no  stimulant 
— and  he  got  brandy  in  large  quantities — roused  him,  and  his 


STATES  OF  MENTAL  STUPOE.  319 

food  did  not  nourish  him.  The  news  of  his  favourite  daughter's 
death  did  not  affect  him.  I  have  no  doubt  he  had  the  delusion 
he  was  dead.  He  got  thinner  and  weaker,  and  gangrene  of 
his  heel  appeared,  then  hypostatic  pneumonia,  and,  lastly, 
gangrene  of  the  lungs,  of  which  he  died  eight  months  after 
admission.  In  the  last  month  of  his  life,  and  especially  when 
his  temperature  rose  to  102*5°  from  the  lung  disease,  he  would 
answer  questions  at  times,  and  once  or  twice  spoke  sensibly, 
asking  what  sort  of  night  he  had  had,  but  generally  he  wanted 
to  be  put  into  his  grave  and  "buried." 

At  the  post-mortem  examination  we  found  considerable 
atrophy  of  the  convolutions,  and  congestion  of  the  brain 
substance. 

No  dramatist  ever  drew  a  more  vivid  picture  of  adversity 
overwhelming  a  man,  striking  him  dumb,  crushing  the  whole 
vitahty  of  mind  and  body  out  of  him,  and  kilKng  him  outright. 
This  was  clearly  an  instance  of  the  power  of  the  mind  over 
the  body,  even  to  the  extent  of  putting  an  end  to  life. 

Anergic  Stupor  {Acute  Dementia). — This  may  be  a  primary 
disease  commencing  without  any  melanchoHc  or  maniacal 
stage,  though  I  have  scarcely  ever  met  with  a  case  in  which 
I  could  not  discover  at  least  a  trace  of  these  conditions  at  the 
beginning  of  the  attack.  Its  symptoms  are  complete  uncon- 
sciousness, and  of  course  no  memory  of  events  that  occurred 
during  its  persistence ;  no  delusions ;  no  muscular  resistance, 
but  in  some  cases  a  static  or  cataleptic  muscular  condition ;  a 
loss  of  facial  expression ;  a  marked  vaso-motor  paresis,  so  that 
the  extremities  are  blue  and  cold ;  a  lowering  of  the  trophic 
energy,  so  that  sores  are  apt  to  form  and  even  gangrene  may 
occur;  the  reflex  functions  of  the  cord  being  markedly 
diminished,  and  the  higher  reflex  functions  of  the  brain 
almost  in  abeyance. 

The  following  case,  E.  P.,  tvas  one  of  anergic  stupor,  occur- 
ring in  a  girl  of  eighteen^  uho  had  had  tioo  slight  attacks  of 
melancholia  on  previo^is  occasions.  One  grandfather  had  been 
melancholic  with  delusions,  but  not  in  an  asylum ;  father  had 


320  STATES   OF   MENTAL   STUPOE. 

several  epileptic  attacks,  and  had.  been  very  "  excitable  "  after 
each;  sister  became  "dazed"  after,  and  in  consequence  of, 
mother's  death,  and  died  of  phthisis  in  four  months ;  and  a 
brother  was  eccentric  and  foolish.  Masturbation  suspected. 
The  attack  began  by  a  short  maniacal  stage,  with  much 
incoherence, — "laughing  in  a  childish  way."  This  passed 
into  a  condition  of  stupor  in  two  months,  during  the  con- 
tinuance of  which  she  never  spoke,  and  stood  in  one  position, 
or  sat  where  she  was  placed.  She  swallowed  hquid  food 
when  put  into  her  mouth,  but  showed  no  desire  for  anything 
nor  interest  in  anything.  Loud  noises  did  not  startle  her. 
She  did  not  obey  the  calls  of  nature.  She  was  cold,  her  feet 
blue  and  swollen,  her  pulse  weak  and  quick,  and  the  reflex 
function  of  the  spinal  cord  abolished.  There  was  no  muscular 
resistance  and  no  catalepsy.  After  about  a  month  she  seemed, 
under  the  use  of  stimulants,  nerve  tonics,  and  blisters  to  the 
occiput,  to  improve  somewhat,  but  she  soon  fell  back  again, 
and  remained  ill  for  over  a  year.  Menstruation,  which  had 
been  absent  for  the  first  six  months,  returned,  and  she  seemed 
to  be  none  the  better  for  it.  As  she  began  to  improve  she 
got  a  httle  obstinate  and  even  violent,  and  her  brain  was  for 
a  time  in  the  repeating  state  one  sees  sometimes  in  certain 
cases  of  mental  disease;  when  asked  a  question  she  would 
repeat  the  words  said,  or  part  of  them,  like  a  parrot,  as  the 
reply.  After  she  began  to  improve  she  rapidly  got  well, 
having  been  previously  fattened  with  milk  diet,  and  she  has 
remained  quite  well  now  for  eleven  years. 

The  folloiving  was  a  case  mih  cataleptic  symjptoms  who 
died. 

E.  Q.,  set.  27,  admitted  2nd  April,.  1881.  Disposition 
bright  and  cheerful.  Habits  steady  and  industrious.  First 
attack.  Ko  hereditary  predisposition.  Cause,  anxiety  in 
regard  to  an  operation  for  removal  of  mammary  tumour  which 
she  had  to  undergo.  Duration  about  five  weeks.  Became 
gradually  depressed,  lost  appetite,  fell  off  in  flesh,  slept  badly. 
Ultimately  became  quite  stupid,  was  unfit  for  her  work,  took 


STATES   OF   MENTAL   STUPOR.  321 

no  interest  in  her  cliildren,  would  stand  in  one  position  for  an 
hour  or  two  continuously,  and  was  very  restless  at  night. 

On  admission  she  was  in  a  state  of  stupor,  paying  no  atten- 
tion to  questions  addressed  to  her  or  to  anything  occurring 
near  her,  would  not  utter  a  word,  stood  in  a  listless  and  stupid 
attitude,  oheyed  no  orders,  refused  food,  did  not  attend  to  the 
calls  of  nature.  She  was  in  very  poor  condition  and  weak 
general  health.  She  was  unresistive,  cold,  and  her  extremities 
blue,  and  her  face  expressed  vacancy,  not  melancholy.  She 
remained  in  this  state  with  the  addition  of  a  degree  of 
catalepsy  for  about  a  year,  when  the  following  was  her  condi- 
tion : — 

A2V'il  3rd. — Slept  well  for  some  hours,  but  was  restless  in 
the  morning.  Eemains  in  a  state  of  stupor,  and  will  not 
speak  a  single  word.  There  is  a  distinct  degree  of  catalepsy. 
Has  taken  plenty  of  food.  To  have  custards,  plenty  of  extra 
milk,  porter,  and  cod-liver  oil  emulsion,  and  friction  to  skin, 
with  extra  warm  clothing. 

The  mental  faculties  seem  blunted  or  dead ;  she  is  utterly 
careless  and  apathetic;  she  is  slovenly  and  dirty,  requiring 
to  be  washed,  dressed,  and  attended  to  in  every  respect ;  she 
never  volunteers  a  remark,  and  indeed  never  utters  a  single 
expression,  except  while  being  bathed  or  dressed,  when  she 
sometimes  gives  vent  to  expressions  of  disapprobation  and 
disgust.  Her  expression  of  face  has  also  changed  of  late. 
Her  general  look  is  one  of  utter  stupidity  and  degradation, 
the  features  being  coarse  and  blurred,  the  saliva  dribbling 
from  the  mouth;  but  frequently,  without  apparent  external 
cause,  the  face  assumes  various  exaggerated  expressions  of 
disgust,  amusement,  and  eroticism,  while  at  times  she  has 
muffled  outbursts  of  chuckling  laughter.  She  takes  plenty  of 
food,  and  is  in  improved  health  and  condition.  Muscularly 
she  is  cataleptic  to  a  marked  degree.  In  the  next  twelve 
months  she  still  further  improved  in  many  respects,  but  she 
then  died  of  diarrhoea. 

The  folloioing  is  a  complicated  case  of  stupor,  catalepsy  with 

X 


322  STATES  OF   MENTAL   STUPOR. 

epilt'iMform  convulsions;  temporary  partial  recovery,  de- 
mentia : — 

E.  S.,  set.  17,  admitted  to  Eoyal  EdinLiirgli  Asylum,  2nd 
May  1874.  Disposition  quiet  and  dull ;  haLits  steady ;  family 
history  not  ascertained ;  assigned  cause  a  severe  blow  on  the 
back  of  the  head  three  years  before  admission,  since  which  he 
has  been  duller  and  more  stupid.  The  injury  seems  to  have 
been  chiefly  spinal.  After  it  he  gradually  lost  complete  con- 
trol over  the  movements  of  his  head — it  "  came  forward  " — 
then  he  ceased  to  be  able  to  stretch  liis  arms  forwards  and 
back,  but  he  still  could  write.  Was  sick,  and  sometimes 
vomited.  Could  not  walk  far  nor  run  at  all  without  being 
very  tired.  Had  pain  in  his  head.  About  three  weeks  ago 
showed  mental  symptoms,  viz.,  rehgious  anxiety,  delusions 
that  his  food  and  medicine  were  poisoned,  shouting, 
violence,  and  dirty  habits.  It  appears  that  an  epileptiform 
fit  immediately  preceded  those  symptoms.  Took  another  fit 
sixteen  days  before  admission,  springing  right  up  from  his 
bed.  Convulsions  lasted  three-quarters  of  an  hour.  During 
the  fit  the  lip  and  tongue  were  bitten.  He  was  then  for  five 
hours  in  "  a  trance."  His  head  had  been  shaved  and  bhstered. 
Had  six  or  seven  fits  subsequent  to  this,  and  before  admission. 

On  admission  he  was  in  a  state  of  stupor  with  no  mentalisa- 
tion  apparent,  insensible  to  pain,  and  spinal  reflex  action 
abolished.  Pulse  130,  weak;  temperature  97"8°j  was  very 
weak ;  u.rine  and  faeces  passed  in  bed. 

He  remained  in  this  stupor,  but  sometimes  cried  and  moaned, 
and  took  many  epileptiform  fits  for  the  first  ten  days.  He  then 
showed  the  true  cataleptic  symptoms,  his  body  assuming  any 
position  it  was  placed  in  for  any  length  of  time.  He  took  no 
notice  of  anytliing,  and  would  not  answer  questions.  One 
evening  the  attendant  got  liim  up,  put  the  chamber-pot  in  his 
hands  under  his  penis,  went  away,  and  forgot  all  about  it,  and 
he  was  found  in  the  same  position  in  the  middle  of  the  night 
by  the  night  attendant.  He  remained  cataleptic  and  uncon- 
scious for  eight  days,  when  he  had  a  feverish  attack  with  diar- 


STATES  OF  MENTAL  STUPOR.  323 

rhoea,  temperature  being  103°.  "While  this  lasted  he  could  be 
roused  to  answer  questions  in  monosyllables,  and  appeared  to 
be  more  conscious  and  intelligent.  After  the  fever  subsided  he 
again  became  completely  cataleptic.  There  collected  and  ran 
out  of  his  mouth  a  foetid  greenish  fluid  somewhat  purulent  in 
character.  Sometimes  he  had  to  be  fed  with  the  stomach  pump. 
The  food  always  had  to  be  made  liquid.  During  all  the  time, 
up  till  August  10th,  he  had  muscular  twitchings  of  the  ex- 
tremities, and  occasionally  a  regular  epileptic  fit.  Pulse  then 
60,  weak  and  irregular  ;  temperature,  98*9°. 

During  September  he  began  to  move  slowly  by  volition  in 
a  snail-Kke  way,  without  speech  or  expression  in  his  face. 
When  up,  and  told  sharply  to  get  into  bed,  he  would  move 
slowly  and  manage  to  get  there  in  half  an  hour  or  so.  Bowels 
very  costive.  When  much  roused,  on  September  17th,  he  got 
up  and  walked  along  the  corridor.  There  were  no  fits  after  the 
18th  September.  He  steadily  improved  after  this,  stiU  being 
slow  and  stupid,  afi'ectively  rehgious,  going  to  church,  and 
saying  very  long  prayers  before  going  to  bed.  In  October 
he  was  able  to  dress,  undress,  go  out  to  do  a  Httle  garden 
work,  but  was  stolid,  slightly  enfeebled  in  mind,  reserved, 
wanting  in  curiosity  and  interest,  and  as  if  he  had  some  latent 
morbid  fancies. 

On  Il^ovember  8,  1875,  he  was  discharged  as  "recovered," 
being  coherent  and  intelHgent,  but  there  was  present  some  of 
the  general  listless  mental  state  referred  to. 

He  did  very  well  at  home  for  a  time,  but  a  process  of  gradual 
mental  enfeeblement  seems  to  have  come  on,  with  irascibihty 
and  sometimes  violence,  so  that,  on  4th  June  1878,  he  was  re- 
admitted to  the  Asylum  in  a  state  of  ordinary  secondary 
dementia.  He  still  remains  there.  He  has  never  had  any 
recurrence  of  the  epileptiform  fits. 

There  are  two  additional  facts  which  one  may  assume,  though 
they  do  not  appear  in  this  record.  The  first  is  that  there  must 
have  been  a  strong  heredity  to  insanity.  The  second  is  that 
the  lad  practised  masturbation  to  excess. 


324  STATES   OF   MENTAL   STUPOK. 

He  says  lie  has  no  recollection  of  what  occurred  during  his 
period  of  stupor.  That  I  believe.  I  look  on  such  a  case  as 
heing  partly  caused  by  adolescence,  compUcated  by  masturba- 
tion and  by  traumatism,  all  of  which  were  concerned  in  the 
causation  of  the  epileptiform  attacks  and  the  condition  of 
stupor. 

Secondary  Stupor. — All  acute  forms  of  mental  disease  are 
liable  to  be  followed,  after  the  acute  symptoms  have  passed  off, 
by  a  condition  of  mental  torpor  and  a  kind  of  mental  enf  eeble- 
ment.  But  this  differs  essentially  from  the  true  secondary 
dementia.  There  is  in  it  to  a  large  extent  the  mental  char- 
acters wliich  I  have  described  as  being  those  of  stupor,  and, 
above  all,  it  is  curable.  The  patients  are  inattentive,  confused, 
lethargic,  and  torpid..  The  brain  reflexes  are  dulled.  The 
energising  of  the  convolutions  is  slow  and  confused.  All  the 
higher  reasoning  and  affective  powers  are  in  abeyance  for  the 
time  being.  It  is  a  time  of  exceeding  importance  for  treatment, 
wliich  should  be  supporting,  tonic,  nutritive,  and  in  some  few 
cases  not  too  exciting ;  though  nerve  stimulants  and  counter- 
irritation  to  the  head  are  often  of  service.  It  is  a  time  for 
moral  and  mental  treatment,  for  regulated  stimulations  of  the 
liigher  centres  by  amusements  and  congenial  work.  The  fact 
that  tliis  state  is  of  frequent  occurrence  should  make  us  guarded 
in  our  prognosis,  and  never  come  hastily  to  the  conclusion 
that  incurable  secondary  dementia  is  present. 

General  Paralytic  and  Epileptic  Stupor. — The  condition  of 
stupor  of  the  anergic  kind  is  often  an  incident  in  those  two 
diseases,  most  frequently  following  attacks  of  convulsions  or 
congestive  attacks,  but  sometimes  coming  on  of  itself  without 
any  reference  to  such  motor  symptoms.  Wherever  there  has 
been  prolonged  stupor  in  general  paralysis  we  find  much  brain 
atrophy  after  death. 

Causation. — The  causes  of  stupor  are  the  following  : — 

1.  Sexual.  The  chief  of  these  is  the  habit  of  masturbation. 
I  have  met  with  it  also  as  a  post-connubial  condition,  or  from 
excessive  sexual  intercourse  in  both  sexes  in  adolescents.     In 


STATES   OF   MENTAL   STUPOR.  325 

some  cases  it  seemed  as  if  the  mental  and  emotional  exalta- 
tion had  acted  as  strongly  as  the  physical  exhaustion.  E.  P. 
(p.  319)  and  E,  S.  (p.  322)  were  examples. 

2.  The  hysterical  condition. 

3.  Mental  and  moral  shocks  (E.  0.  A.,  p.  318),  and  over- 
work during  adolescence  (E.  M.,  p.  310). 

4.  The  brain  exhaustion  caused  by  acute  mental  diseases, 
more  especially  acute  mania. 

5.  Stupor  often  occurs  as  an  incident  or  stage  in  other 
mental  diseases,  notably,  as  we  have  seen,  in  general  paralysis 
and  epilepsy. 

6.  An  alcoholic  stupor  may  be  caused  by  excessive  drinking, 
and  is  thus  one  form  of  alcoholic  insanity  (E.  JST.,  p.  310). 
Such  a  condition  is  usually  transitory,  but  not  always. 

7.  Stupor  is  frequently  one  of  the  stages  of  alternating  in- 
sanity following  the  exalted  condition.  It  is  more  apt  to 
occur  in  those  where  the  exalted  period  is  acutely  maniacal. 
This  stupor  is  usually  the  melancholic  form.  The  older  the 
patient  the  more  apt  is  the  stage  of  reaction  after  exaltation 
to  be  one  of  stupor.  I  had  once  under  my  care  an  old 
gentleman  of  84,  who,  when  his  periods  of  exaltation  were  un- 
usually long,  would  afterwards  become  torpid,  never  speak  nor 
take  any  notice  of  anything,  would  not  even  stand,  but  must 
be  kept  in  bed,  would  scarcely  swallow,  and  this  would  some- 
times continue  for  four  or  five  weeks  (and  see  case  D.  E.,  p.  231). 
"When  younger  he  never  had  such  attacks.  He  has  laboured 
under  irregularly  alternating  insanity  for  thirty  years. 

8.  Adolescence  alone,  as  in  the  case  of  E.  P.  (p.  319). 

9.  Senility.  In  the  extremest  form  of  senile  insanity  the 
mental  faculties  sometimes  disappear  so  entirely  as  to  con- 
stitute stupor. 

10.  It  is  sometimes  the  chief  mental  symptom  of  brain 
atrophy. 

Some  of  these  causes  may,  of  course,  co-exist,  and  they  are 
all  apt  to  be  aggravated  by  the  existence  of  a  strong  hereditary 
predisposition  to  insanity. 


326  STATES   OF  MENTAL   STUPOE. 

Prognosis  in  Stupor. — In  its  typical  form,  in  young  persons 
of  both  sexes,  the  anergic  form  (acute  dementia)  is  a  very 
curable  form  of  mental  disease.  The  melancholic  form  is  not 
so  curable,  but  about  50  per  cent,  of  the  cases  recover. 

Pathology. — There  is  undoubted  vaso-motor  paresis  along 
with  diminution  or  even  aboHtion  of  many  of  the  cerebral 
reflexes.  A  case  of  deep  stupor  exhibits  the  nearest  approach 
we  yet  know  to  a  complete  temporary  suspension  of  all  the 
higher  cerebral  centres.  Dr  Wiglesworth^  has  carefully  in- 
vestigated the  condition  of  the  cortex  in  certain  very  deep  and 
fatal  cases  of  stupor  with  motor  symptoms.  He  describes 
and  figures  globose,  granular,  and  pigmented  cells,  some  with 
the  beginning  of  vacuolation  of  nuclei.  The  following  are  his 
general  conclusions  : — "  That  from  the  ill-defined  assemblage 
of  cases  commonly  called  '  Melancholia,' '  Melancholia  Attonita,' 
and  '  Acute  Dementia,'  a  group  has  to  be  distinguished  which 
constitutes  a  definite  chnical  and  pathological  entity.  That 
tills  group  is  chnically  characterised  by  the  association  of  more 
or  less  of  self-absorption  passing  into  vacuity,  with  a  definite 
affection  of  the  muscular  system,  to  wit,  muscular  tremors  and 
muscular  rigidity.  That  the  pathological  basis  of  the  same 
is  a  primary  inflammatory  affection  of  nerve  cells,  best 
marked  in  the  so-called  'motor  cells,'  and  possibly  originating 
in  these,  but  showing  a  decided  tendency  to  spread  beyond 
their  area." 

Treatment  of  Stupor. — All  forms  require  much  the  same 
treatment,  but  in  the  anergic  cases  it  needs  to  be  supporting 
and  stimulating,  and  in  the  melanchoHc  more  supporting  at 
first,  and  stimulating  afterwards.  Quinine,  iron,  strychnine 
pushed  to  large  doses,  ergot,  digitalis,  warmth,  the  continued 
current,  exercise,  friction,  alcohohc  stimulants,  rousing  moral 
treatment,  occupation,  distraction  of  mind,  are  the  general  indi- 
cations. In  the  relation  of  the  chnical  histories  of  the  cases 
described,  the  details  of  treatment  have  been  sufficiently  spoken 
of. 

^  Journal  of  Mental  Science,  Oct.  1883. 


LECTUEE    IX. 

STATES  OF  DEFECTIVE  INHIBITION  {PSYCHO- 
KIN  ESI  A  ;  HYPERKINESIA ;  INHIBITORY 
INSANITY ;  IMPULSIVE  INSANITY;  INSANE 
IMPULSE;  VOLITIONAL  INSANITY;  UN- 
CONTROLLABLE IMPULSE  ;  INSANITY  WITH- 
OUT DELUSION,  EXALTATION,  DEPRESSION, 
OR  ENFEEBLEMENT) ;  THE  INSANE  DIA- 
THESIS. 

Self-control  ia  the  popular  sense — Sane  self-control  need  not  be  perfect ; 
variation  in  amount  of,  in  different  persons,  ages,  and  conditions  of 
society  ;  laws,  natural  and  human,  should  teach  it — Physiological 
view  of  inhibition  in  a  child  ;  its  absence  at  first  ;  its  gradual  growth 
with  brain  development  ;  degrees  of  inhibition  and  of  account- 
ability ;  conscience  as  a  physiological  brain  quality  ;  children  of 
criminals  and  of  the  insane  ;  organic  lawlessness — Self-control 
affected  in  all  insanities  ;  want  of  inhibitory  power  and  morbid 
impulse  as  an  insanity,  without  other  morbid  mental  symptoms — 
Uncontrollable  motor  impulses ;  coughing  ;  sudden  acts  of  defence 
and  offence ;  exhaustion  lessens  controlling  power  ;  meaning  of 
irritability  ;  existence  of  obscure  tendencies  to  kill,  destroy,  &c.,  in 
mankind — Doctrine  of  inhibitory  centres  of  motion,  nutrition,  and 
mental  action  ;  Laycock's  doctrine  of  reflex  function  of  brain  ;  illus- 
trated by  maternal  instinct  in  cats — Illustrations  and  cases  of 
impulsive  but  reasoning  insanity  ;  epileptiform  character  in  some 
cases  ;  hereditary  connection  with  epilepsy  ;  impulsive  acts  by  sug- 
gestion ;  brain  acting  automatically,  just  as  muscles  do  during  sleep, 
in  coughing,  speaking,  &c. — Action  from  impulse,  either  by  loss  of 
controlling  power,  or  by  an  excessive  production  of  energy  that  must 
find  an  outlet  somewhere — Conscious  and  unconscious  impulsive 
action  ;  medico-legal  importance  and  difficulty  of  uncontrollable 
action  from  impulse — Defective  inhibition  may  affect  every  kind  of 
action,  every  kind  of  affective  state,  and  every  propensity  and 
instinct ;  degree  of  strength  ;  may  result  in  no  action,  but  merely  a 


328  STATES   OF   DEFECTIVE   INHIBITION. 

desire  to  act.  Etiology :  Heredity  ;  sunstroke  ;  effects  of  alcohol  on 
brain  and  offspring  ;  injuries  to  brain  ;  congenital  defects  ;  want 
of  or  bad  early  training  ;  "  moral  idiocy  ;  "  "  instinctive  juvenile 
mania ;  "  visceral  derangement  and  reflex  irritation ;  first  symptoms 
of  mania  or  other  insanity.  Prognosis :  Depends  on  causes  ;  some 
of  the  worst  and  most  hopeless  cases  of  insanity  as  well  as  the  most 
dangerous  and  troublesome  of  this  class,  and  some  of  the  slightest. 
Treatment :  Protective  to  self  and  others  ;  change  of  scene,  and 
removal  from  association  of  morbid  ideas  ;  Medical,  by  improving 
health,  strengthening  nervous  tone,  removing  visceral  or  other 
irritation,  the  bromides  and  sedatives  ;  regimen,  brain  rest  and 
muscular  exertion,  nutritive  non-stimulating  diet,  no  alcohol ; 
educative  in  young  psychokinetics.  Vakieties — {a)  General 
Imxndsiveness  (Psychokinesia) :  Lack  of  control  or  impulse  in  all 
directions  ;  to  kill,  towards  suicide,  to  break  and  destroy,  to  sexual 
acts,  &c.  (&)  EinlciMform  Impulse :  Impulsiveness  the  mental 
characteristic  of  epileptics  ;  "  mental  explosion  ; "  masked  epilepsy, 
(c)  Animal  and  Organic  Impulse :  Perverted  sexual  impulses,  taking 
forms  of  impulsive  masturbation,  sodomy,  incest,  rape  on  children, 
beastiality  ;  perversion  of  other  appetites,  propensities,  and  instincts, 
e.g.,  urine  drinking,  eating  stones,  rags,  nails  ;  infinite  variety  of 
such  impulses,  {d)  Homicidal  Impulse  :  Medico-Legal  importance  ; 
examples  ;  letter  of  medical  man  suffering  from  this,  &c.  (e)  Suicidal 
Impulse :  Conscious  or  unconscious  ;  with  or  without  depression  of 
mind  ;  by  suggestion  ;  instinct  of  love  of  life  perverted  ;  most  com- 
mon of  all  impulses.  (/)  Destructive  Impidse :  Takes  the  form  of 
breaking,  tearing,  smashing,  &c.,  with  no  other  tendency  ;  the 
glass  smasher,  {g)  Dipsomania  :  Importance  ;  causation,  neurotic 
or  drunken  heredity,  excess  in  drinking,  injuries  to  head,  losses  of 
blood  and  bodily  weakness,  bad  hygienic  conditions  and  employ- 
ments, slight  mental  weakness  combined  with  neurotic  diathesis, 
senility,  first  stage  of  maniacal  conditions,  special  functional  condi- 
tions, e.g.,  menstruation,  pregnancy,  &c.  Symptoms:  craving  for 
alcohol  and  all  stimulants,  lying,  general  demoralisation,  falling  in 
social  scale,  loss  of  all  self-respect,  cringing,  self-indulgence,  irresolu- 
tion, loss  of  affection.  Treatment  :  abstinence,  isolation,  work, 
healthy  food,  regimen,  and  conditions  of  life.  Prognosis  :  bad  in 
most  cases,  (h)  Kleptoinania :  Rare  in  uncomplicated  form,  but 
this  impulse  very  common  in  many  forms  of  insanity,  especially  in 
General  Paralysis,  and  less  so  in  Mania  and  Congenital  Imbecilitj'. 
{i)  Pyromania :  Rare  in  uncomplicated  form,  {j)  Moral  Insanity  : 
Congenital  absence  of  sense  of  right  and  wrong,  and  incapacity  for 
moral  education.  As  a  matter  of  fact,  we  find  persons  with  no  moral 
sense,  no  remorse,  no  love  of  the  good,  but  a  love  of  and  impulse  to 
do  every  evil  thing.     Conscientiousness  hereditary. 


STATES   OF   DEFECTIVE   INHIBITION.  329 

Self -Control — Mental  Inhibition. — The  want  of  the  power 
of  self-control  is  so  very  common  a  thing  amongst  mankind, 
that  to  some  extent,  and  in  respect  to  some  matters,  it  may 
be  regarded  as  the  normal  condition  of  our  species.  A  perfect 
capacity  of  self-control  in  all  directions  and  at  all  times  is 
rather  the  ideal  state  at  which  we  aim  than  the  real  condition 
of  any  of  us.  The  men  who  have  attained  this  state  of  in- 
hibitory perfection  have  been  few  and  far  between,  and  even 
in  regard  to  them  it  may  be  said  that  they  too  would  have  lost 
their  self-control  if  they  had  been  exposed  to  sufficient  tempta- 
tion or  irritation.  But  while  a  perfect  mental  inhibition 
may  not  be  attainable,  there  is  a  certain  amount  of  this 
power  in  all  directions,  and  an  absolute  power  in  some 
directions  that  is  expected  of  all  sane  persons.  All  sane 
men  must  control  to  some  extent  their  animal  desires,  and 
they  must  control  absolutely  any  desires  they  may  have 
towards  homicide.  The  law  assumes,  as  the  basis  of  all  its 
enactments,  that  all  men  have  the  inherent  power  to  do  certain 
things  and  avoid  other  tilings  that  would  be  inconsistent  with 
the  well-being  of  society,  or  the  safety  or  comfort  of  their 
fellow-men.  A  man  is  born  of  criminal  parents,  and  has 
been  taught  to  prey  on  his  fellows  and  look  on  them  as  having 
no  rights  that  he  is  bound  to  respect,  from  no  fault  of  his 
own  his  brain  is  weak,  and  no  sense  of  right  and  wrong  has 
been  implanted  in  him,  yet  in  spite  of  all  this  he  is  held  as 
fully  responsible  by  the  law  and  is  punished  in  the  same 
degree  as  the  strongest,  best-taught,  and  most  favourably 
circumstanced  man  in  the  country ;  and  this  is  at  present 
unavoidable,  however  unscientific  it  is  from  the  physiological 
and  psychological  aspect  of  brain  and  mind  function.  Human 
laws  are,  after  all,  largely  the  reflexes  of  the  laws  of  nature. 
If  a  man  has  not  been  taught  that  an  excessive  use  of  alcohol 
damages  or  kills,  and  he  drinks  it  to  excess,  he  sufi'ers  just  as 
much  as  the  man  who  knows  its  bad  effects  and  deliberately 
poisons  liimself  with  it.  But  to  this  assumed  power  of  mental 
control  in  all  men  the  law  makes  certain  exceptions.     The 


330  STATES   OF  DEFECTIVE   INHIBITION. 

first  of  these  is  in  regard  to  children,  and  the  second  is  in 
regard  to  persons  whose  mental  power  has  been  affected  by 
disease  or  want  of  brain  development. 

Degrees  of  Control. — The  subject  of  mental  inhibitory  power 
should  first  be  studied  by  us  medical  men  from  the  point  of 
view  of  its  gradual  development  in  children.  Take  a  child  of 
six  months,  and  there  is  absolutely  no  such  brain  power  exist- 
ent as  mental  inhibition — no  desire  nor  tendency  is  stopped 
or  controlled  by  a  mental  act.  At  a  year  old  the  rudiments 
of  the  great  faculty  of  self-control  are  clearly  apparent  in  most 
children.  They  will  resist  the  desire  to  seize  the  gas  flame, 
they  will  not  upset  the  milk  jug,  they  will  obey  orders  to  sit 
still  when  they  want  to  run  about,  all  through  a  higher  mental 
inlnbition.  But  the  power  of  control  is  just  as  gradual  a 
development  as  the  motions  of  the  hands.  There  is  no  day 
or  year  in  a  child's  life  after  which  killing  its  little  brother  is 
murder,  and  before  which  it  was  no  crime  at  all.  The  law 
admits  and  provides  in  a  rough  way  for  this  physiological  fact 
as  to  self-control,  by  admitting  no  responsibility  for  crime, 
and  exempting  entirely  from  punishment,  if  committed  before 
the  age  of  seven,  and  by  taking  each  case  between  seven  and 
fourteen  into  special  consideration  as  to  whether  there  was 
responsibility  or  not.  We  physicians  see  that  this  faculty  is 
developed  at  different  ages  in  different  cases.  We  are  bound  to 
give  credence  to  all  physiological  facts  and  laws,  and  it  is  as 
much  a  fact  that  different  brains  have  different  degrees  of  con- 
trolling power  after  their  full  development,  as  it  is  that  they 
attain  their  power  of  control  at  different  ages.  As  we  watch 
children  grow  up  we  see  that  some  have  the  sense  of  right 
and  wrong,  the  conscience,  developed  much  sooner  and  much 
stronger  than  others,  just  as  some  have  their  eye-teeth  much 
sooner  than  others  ;  and  looking  at  adults,  we  see  that  some 
never  have  much  of  this  sense  developed  at  all.  This  is 
notoriously  the  case  in  some  of  those  whose  ancestors  for 
several  generations  have  been  criminals,  insane,  or  drunkards. 
Then,  again,  in  other  persons,  the  sense  of  right  and  wrong  is 


STATES   OF   DEFECTIVE  INHIBITION.  331 

painfully  keen  from  early  childhood,  and  the  desire  to  follow 
the  one  and  avoid  the  other  earnestly  striven  after  from  the 
first.  In  some,  therefore,  conscience  is  anaesthetic,  in  others 
hyperaesthetic,  just  as  sensation  may  be.  ^Notoriously  it  is  a 
bad  tiling  to  force  any  sense  or  mental  faculty  into  too  great 
activity  till  its  brain  substratum  is  sufficiently  developed.  I 
have  known  many  children  whose  anxious  parents  had  made 
them  morally  hypersesthetic  at  early  ages  through  an  ethical 
forcing-house  treatment.  I  knew  one  little  boy  of  four,  who, 
by  dint  of  constant  effort  on  the'  part  of  his  mother,  was  so 
sensitive  as  to  right  and  wrong,  that  he  never  ate  an  apple 
without  first  considering  the  ethics  of  the  question  as  to  whether 
he  should  eat  it  or  not ;  who  would  suffer  acute  misery,  cry 
bitterly,  and  lose  some  of  Ms  sleep  at  night  if  he  had  shouted  too 
loud  at  play  or  taken  more  than  his  share  of  the  cake,  he  having 
been  taught  that  these  things  were  "  wrong  "  and  "  displeasing 
to  God."  But  the  usual  anaesthesia  that  follows  too  keen  feeling 
succeeded  to  the  precocious  moral  intensity  in  this  child,  for 
at  ten  he  was  the  greatest  imp  I  ever  saw,  and  could  not  be 
made  to  see  that  smashing  his  mother's  watch,  or  throwing  a 
cat  out  of  the  window,  or  taking  what  was  not  his  own,  were 
wrong  at  all.  We  know  that  some  of  the  children  of  many 
generations  of  thieves  take  to  stealing  as  a  young  wild  duck 
among  tame  ones  takes  to  hiding  in  holes,  and  that  the  children 
of  savage  races  cannot  copy  at  once  our  ethics  nor  our  power  of 
controlling  our  actions.  It  seems  to  take  many  generations  to 
re-develop  an  atrophied  conscience.  Professor  Benedikt  of 
Vienna  showed,  at  the  International  Medical  Congress  of  1881 
in  London,  a  number  of  brains  of  habitual  criminals  whicli  he 
affirmed  had  their  convolutions  arranged  in  a  certain  simple 
form  peculiar  to  the  criminal  classes,  so  that  on  seeing  such  a 
brain  he  could  tell  the  general  ethical  tendencies  of  the  person 
to  whom  it  belonged,  just  as  you  can  tell  a  dog  to  be  a  bull 
dog  by  liis  jaws.  There  is  no  doubt  that  an  organic  lawless- 
ness is  transmitted  hereditarily.  Among  the  many  transmitted 
morbid  peculiarities  in  the  children  of  neurotic  and  insane 


332  STATES    OF   DEFECTIVE   INHIBITION. 

parents  this  is  often  one.  Either  a  too  morhid  incensity 
of  desire,  or  a  morbid  weakness  of  control,  renders  such 
children  prone  to  early  morbid  immoralities. 

In  the  dehrinm  of  fevers  and  the  ravings  of  the  acixter 
forms  of  insanity,  no  form  of  seK-control  is  expected.  The 
law,  from  the  earliest  times,  entirely  exempted  persons  suffering 
from  such  conditions  from  responsibility  for  acts  done  under 
their  influence.  A  study  of  the  different  varieties  of  insanity 
shows  us  that  the  power  of  self-control  differs  enormously 
in  the  various  forms,  and  in  different  individuals  labouring 
under  the  same  form,  while  there  is  no  hne  of  demarcation 
between  the  state  in  which  a  man  has  "perfect  self-control" — 
to  use  an  expression  that  cannot  be  literally  true  in  any  case 
— and  that  in  which  he  has  none  at  all.  Self-control,  in 
short,  Kke  all  physiological  quahties  and  all  mental  faculties, 
exists  in  every  possible  degree  of  strength.  Sufficient  power 
of  self-control  should  be  the  essence  and  legal  test  of  sanity, 
if  we  had  any  means  of  estimating  it  accurately.  The 
accurate  clinical  study  of  mind  in  relation  to  its  ordinary 
physiological  accompaniments  in  health  and  disease  will, 
I  believe,  help  us  in  time  to  make  such  an  estimate  in  any 
particu.lar  case  far  more  accurately  than  we  are  now  able 
to  do.  The  practising  physician,  from  his  daily  acquaintance 
with  the  physiological  facts  of  nature,  instinctively  makes 
allowances  for  lack  of  self-control  in  his  patients  when  they 
are  ill,  apart  from  technical  insanity.  He  knows  that  the 
thing  called  "irritability"  usually  means  lack  of  full  vital 
power,  that  the  "impulses"  of  the  hysterical  girl  are  simply 
morbidly  transformed  modes  of  energy  temporarily  bursting 
the  bounds  of  the  patient's  will,  just  as  fits  of  weeping  are 
often  involuntary  and  uncontrollable.  But  the  lawyer,  and 
the  medical  man  who,  as  a  medico-legal  witness  or  adviser, 
has  to  consider  the  social  and  legal  aspect  and  effect  of  his 
opinions,  are  always  chary  of  admitting  mere  loss  of  control 
or  morbid  impulse  as  an  excuse  for  crime.  They  both  like 
to  have  other  evidence  of  disorder  of  the  mental  function. 


STATES   OF  DEFECTIVE  INHIBITION.  333 

in  the  shape  of  insane  delusion  or  incoherence  of  speech, 
before  they  are  willing  to  put  forward  the  plea  of  diseased 
want  of  self-control  in  mitigation  of  legal  punishment. 
Another  element  than  medical  facts  comes  in  then,  viz., 
the  practical  effect  of  their  opinions  on  society.  In  a  com- 
munity of  perfectly  law-abiding  people  a  murder  would 
naturally  be  attributed  to  disease,  and  no  objection  would 
be  taken  by  any  one  to  that  view  of  it.  But  with  the  world 
as  it  exists  it  is  different. 

Before  we  can  give  any  opinion  as  to  the  responsibility  or 
irresponsibility  of  any  case  in  a  court  of  law,  we  should  see 
as  many  cases  as  we  can  where  want  of  controlling  power 
or  impulsive  tendencies  constitute  the  disease  or  the  chief 
part  of  it.  Such  cases  exist,  though  they  are  not,  in  a  pure 
form,  very  numerous.  As  one  stage  in  cases  of  insanity 
they  are  frequent.  Half  the  suicidal  melancholies  at  the 
beginning  dread  the  moment  when  their  self-control  will 
be  lost.  Many  of.  the  maniacal  cases  show  at  an  early  stage 
only  loss  of  self-control,  before  motor  excitement  or  incohe- 
rence comes  on.  If  one  has  seen  many  persons  in  this  state 
about  whom  there  could  be  no  doubt  as  to  their  disease, 
and  if  one  has  systematically  studied  the  loss  of  self-control 
or  morbid  impulse  as  a  mental  symptom  in  the  various  forms 
it  is  found  to  assume,  such  experience  and  study  bring  much 
confidence  to  us  in  giving  private  medical  advice  about  this 
matter,  or  in  giving  evidence  in  the  witness-box  in  regard 
to  one  of  the  most  responsible  and  difficult  questions  about 
which  a  medical  man  has  to  come  to  a  decision. 

Inhibition,  Motor  and  Mental. — Consider  first  the  variety  of 
simple  motor  impulses  or  acts  that  are  physiologically  uncon- 
trollable, or  partly  so,  such  as  coughing,  vomiting,  &c.  ]^ext, 
look  at  a  more  complicated  act,  that  will  be  recognised  by  any 
competent  physiologist  to  be  automatic,  and  beyond  the  control 
of  any  ordinary  inhibitory  power,  e.g.,  irritate  and  tease  a 
young  child  of  one  or  two  years  sufficiently,  and  it  will  strike 
out  at  you ;  suddenly  strike  a  man,  and  he  will  either  perform 


334  STATES   OF   DEFECTIVE   INHIBITION. 

an  act  of  defence  or  offence,  or  botli,  quite  automatically, 
and  without  power  of  controlling  himself.  Place  a  bright 
tempting  toy  before  a  child  of  a  year,  and  it  will  be  instantly 
appropriated.  Place  cold  water  suddenly  before  a  sane  man 
dying  of  tliirst,  and  he  will  take  and  drink  it  -without 
power  of  doing  otherwise.  Exhaustion  of  nervous  energy 
always  lessens  the  inhibitory  power.  "Who  is  not  conscious 
of  this  1  "Irritability  "  is  one  manifestation  of  this.  Many 
persons  have  so  small  a  stock  of  reserve  brain  power — that 
most  valuable  of  all  brain  quahties — that  it  is  soon  used 
up,  and  they  then  lose  their  power  of  self-control.  They 
are  angels  or  demons  just  as  they  are  fresh  or  tired.  The 
surplus  store  of  energy  or  resistive  force  which  provides 
in  persons  normally  constituted  that  moderate  excesses  in 
all  directions  shall  do  no  great  harm,  so  long  as  they  are 
not  too  often  repeated,  not  being  present  in  those  people, 
over-work,  over-drinking,  or  small  debauches  leave  them 
at  the  mercy  of  their  morbid  impulses  without  power  of 
resistance.  Some  persons  of  more  mental  and  nerve  force 
have  the  fatal  power  of  keeping  themselves  at  work  or  at 
dissipation  till  this  surplus  reserve  stock  of  resistiveness 
is  altogether  exhausted,  and  they  then  become  completely 
unresistive  against  morbid  impulses.  Woe  to  the  man  who 
uses  up  his  surplus  stock  of  brain  inhibition  too  near  the 
bitter  end,  or  too  often  ! 

In  relation  to  the  medico-psychological  problems  of  mental 
inhibition  and  impulse,  we  have  to  take  into  account  those 
obscure  human  tendencies  towards  killing,  towards  destructive- 
ness,  towards  appropriation,  towards  unrule,  some  of  which 
exist  as  inchoate  physiological  tendencies  more  or  less  strong  in 
most  human  beings,  and  the  gratifying  of  which  gives  pleasure. 
They  are  best  seen  in  youth,  and  they  often  come  out  in  a  strong 
way  in  disease.  Be  they  transmitted  qualities  of  our  far-oflf  pro- 
genitors, or  physiological  weapons  to  help  us  in  the  struggle  for 
existence,  or  other  and  normal  physiological  energies  transmuted, 
there  they  are,  and  we  must  accept  them  as  facts  of  nature. 


STATES   OF  DEFECTIVE  INHIBITION.  ,  335 

The  doctrine  of  nervous  inhibition  and  of  inhibitory  centres 
has  done  very  much  to  definitise  our  notions  in  regard  to  the 
mental  working  of  the  brain.  There  is,  of  course,  no  positive 
proof  of  mental  inhibitory  centres,  but  there  is  mental  in- 
hibition, and  a  function  always  implies  an  organ  of  some 
sort.  When  it  was  demonstrated  that  the  excitation  of 
certain  nerves  caused,  not  motion,  but  stoppage  of  motion ; 
when  it  was  proved  that  the  nutrition  of  the  tissues  was 
largely  influenced  by  the  increased  or  diminished  patency  of  the 
capillaries  and  arterioles,  and  that  the  latter  was  dependent 
on  two  sets  of  nerves  and  two  sets  of  centres,  one  to  open  and 
the  other  to  shut  those  vessels,  such  physiological  facts  were 
at  once  correlated  with  the  facts  observed  in  conditions  of 
mental  excitation  and  depression,  mental  quickening  and 
slowing,  emotional  supersensitiveness  and  torpor,  and  the 
conclusion  was  arrived  at  that  in  the  higher  department  there 
must  be  a  somewhat  similar  apparatus  for  regulating  the  exer- 
cise of  the  mental  functions  of  the  brain,  and  that  disorders 
of  these  would  probably  make  all  the  difference  between  sanity 
and  insanity,  between  self-control  and  insane  impulse.  That 
there  was  a  physiological  analogy  between  the  jactitation  of 
the  limbs  of  a  man  with  chorea,  who  tries  to  control  these 
motions  but  is  not  able  to  do  so,  and  the  insane  impulses  to 
murder,  suicide,  and  violence  which  the  patients  are  aware 
of,  deplore,  and  fruitlessly  try  to  resist  but  are  unable  to  do 
so,  seemed  very  evident.  In  the  one  case,  a  controlling  centre 
or  centres  of  motion  are  not  doing  their  work,  either  from 
absolute  loss  of  their  own  internal  power  of  governance  or  from 
an  excess  of  energy  generated  in  the  lower  motor  centres  of 
the  choreic  limbs;  in  the  other,  the  controlling  centres  of 
mentahsation  and  feeling  are  not  doing  their  work  for  the 
same  reasons.  We  know  that  there  are  controlling  centres  of 
many  of  the  lower  reflex  functions,  and  there  can  be  no  doubt 
that  they  exist  also  to  control  the  great  reflex  functions  of 
the  cerebrum,  which  were  so  clearly  expounded  by  Laycock. 
That  doctrine  has  done  much  to  make  us  understand  better 


336  STATES   OF  DEFECTIVE  liJHimTI^ 

the  mental  functions  of  the  brain  and  their  derangements. 
•  Let  us  glance  at  an  example.  The  maternal  instinct  of  care 
and  affection  for  offspring  is  a  mental  function  of  brain 
common  to  man  with  the  lower  animals,  and  ranks  next  to 
the  love  of  hfe  and  the  desire  to  reproduce  the  species  in 
importance,  while  it  equals  these  in  conscious  intensity  for  the 
time  it  is  in  operation.  Its  periods  of  activity  are,  of  course, 
intimately  connected  with  the  activity  of  the  reproductive 
organs.  The  objects  of  the  instinct  need  not  necessarily  be 
the  animal's  own  offspring.  Cats  will  suckle  and  take  tender 
care  of  young  rabbits  when  their  maternal  instinct  is  in  full 
activity  after  parturition  and  when  the  mammae  are  function- 
ally active.  There  is  a  nervous  influence  sent  up  from  these 
organs  to  some  portion  of  the  brain,  rousing  it  into  activity, 
and  so  developing  the  feeling  for  young,  and  the  unceasing 
innumerable  acts  of  care,  defence,  playing  with,  and  protection, 
which  for  the  time  dominate  the  whole  mental  life  and  out- 
ward actions  of  the  animal.  Artificial  irritation  of  the 
mammae  without  previous  parturition  will  sometimes  develop 
this  instinct.  In  the  case  of  the  cat  suckhng  the  young 
rabbits,  it  entirely  inhibits  the  opposite  instinct  to  kill  and 
eat  them.  In  conditions  of  disease  the  maternal  instinct  may 
be  completely  perverted  in  its  exercise,  so  that  animals  some- 
times eat  and  destroy  their  young.  K'ow,  the  same  thing 
happens  in  the  human  species.  In  the  insanity  which  occurs 
after  childbirth  one  of  the  most  common  symptoms  is  either 
an  entire  inhibition  of  the  maternal  instinct,  so  that  "  a 
woman  forgets  her  sucking  child,"  or  an  entire  perversion 
of  it,  so  that  she  wants  to  destroy  her  own  offspring. 

Fornis  of  Impulse. — The  physiological  word  "mhibition" 
can  therefore  be  used  synonymously  with  the  psychological 
and  ethical  expression  "  self-control,"  or  with  the  "  will "  when 
exercised  in  certain  directions.  It  is  the  characteristic  of 
most  forms  of  mental  disease  for  self-control  to  be  lost,  but 
this  loss  is  usually  part  of  a  general  mental  affection  with 
melanchohc,  maniacal,  demented,  or  delusional  symptoms  as 


STATES   OF  DEFECTIVE  INHIBITION.  337 

the  cliief  manifestations  of  the  disease.  The  cases,  not  so 
numerous,  where  the  loss  of  the  power  of  inhibition  is  the  chief 
and  by  far  the  most  marked  symptom,  we  are  now  to  consider 
and  study."  I  shall  call  this  form  "inhibitory  insanity." 
Some  of  these  cases  have  uncontrollable  impulses  to  violence  and 
destructiveness,  others  to  homicide,  others  to.  suicide  prompted 
by  no  depressed  feelings  or  delusions,  others  to  acts  of  sexual 
gratification  (satyriasis,  nymphomania,  erotomania,  bestiality), 
others  to  drinking  too  much  alcohol  (dipsomania),  others 
towards  setting  things  on  fire  (pyromania),  others  to  stealing 
(kleptomania),  and  others  towards  immoralities  of  all  sorts 
(moral  insanity).  The  impulsive  tendencies  and  morbid  de- 
sires are  innumerable  in  kind.  Many  of  these  varieties  of 
insanity  have  been  distinguished  by  distinct  names  :  to  dig  up 
and  eat  dead  bodies  (necrophilism),  to  wander  from  home  and 
throw  off  the  restraints  of  society  (planomania),  to  act  like  a 
wild  beast  (lycanthropia),  &c.  Action  from,  impulse  in  all 
these  directions  may  take  place  from  a  loss  of  controlling  power 
in  the  higher  regions  of  the  brain,  or  from  an  over-develop- 
ment of  energy  in  certain  portions  of  the  brain,  which  the 
normal  power  of  inhibition  cannot  control.  The  driver  may 
be  so  weak  that  he  cannot  control  well-broken  horses,  or  the 
horses  may  be  so  hard-mouthed  that  no  driver  can  pull  them 
up.  Both  conditions  may  arise  from  purely  cerebral  disorder, 
or  from  cerebral  excitation  or  paralysis  caused  by  eccentric 
agency  in  the  organs— it  may  be  reflex,  in  short.  The  former 
of  these  may  be  without  consciousness  at  all,  the  ego,  the  will, 
the  man  being  non-existent  for  the  time.  The  most  perfect 
examples  of  this  are  murders  done  during  somnambulism  or 
epileptic  unconsciousness,  or  acts  done  in  the  hypnotic  state. 
There  is  no  conscious  desire  to  attain  the  object  at  all  in  such 
cases.  In  other  cases  there  are  consciousness  and  memory 
present,  but  no  power  of  restraining  action.  The  simplest 
example  of  this  is  where  an  imbecile  or  a  dement,  seeing  some- 
thing glittering,  appropriates  it  to  himself,  or  when  he  commits 
indecent  sexual  acts.     Through  disease  a  previously  sane  and 

Y 


338  STATES   OF  DEFECTIVE   INHIBITION. 

vigorous-minded  person  may  get  into  tliis  state,  Tlie  motives 
that  would  lead  persons  in  health  not  to  do  such  acts  do  not 
operate  in  such  persons,  I  have  known  a  man  steal  who  said 
he  had  no  intense  longing  for  the  article  he  appropriated  at 
all,  at  least  consciously,  hut  his  will  was  in  aheyance,  and  he 
could  not  resist  the  ordinary  desire  of  possession  common  to  all 
human  nature.  I  have  known  a  married  man  with  opportunity 
of  sexual  intercourse  indulge  in  masturbation,  his  reason  tell- 
ing him  the  act  was  wrong,  and  his  feehng  causing  disgust 
and  regret,  yet  he  could  not  resist  this  simple  but  unnatural 
mode  of  sexual  excitation.  Vohtion  and  resistive  power  were 
paralysed. 

The  second  class  of  impulsive  acts,  where  we  seem  to  have 
normal  vohtional  power,  but  the  impulses  so  morbid  and  so 
strong  that  they  cannot  be  resisted,  is  often  seen  by  the'physician 
in  the  early  stages  of  mental  disease,  before  its  symptoms  have 
fully  developed.  Its  existence  may  be  ridiculed  by  journalists, 
and  the  dangers  of  admitting  its  existence  may  be  painted  in 
dark  colours  by  lawyers,  but  that  it  exists  as  a  fact  in  the 
history  of  human  nature  no  one  can  doubt  who  has  actually 
seen  the  terror  and  agony  of  a  mother  conscious  of  an  impulse 
to  destroy  her  child,  and  striving  against  it  with  vehement 
resolution.  A  lady  came  to  me  lately  to  consult  me,  and  this 
was  part  of  her  conversation  : — "  Thoughts  of  putting  myself 
away  come  suddenly  into  my  mind  when  I  am  working  and 
quite  cheerful.  Oh !  my  God  !  if  I  could  get  these  thoughts 
out  of  my  head  what  would  I  not  give  ?  I  could  and  do 
scream  for  relief  sometimes.  Oh,  me  !  it's  horrible !  It 
comes  on  me  that  some  day  I  will  take  away  my  hie  or  that 
of  •  my  children.  I  had  this  idea  before  I  was  married  at 
times.  My  mother  had  it.  It  comes  on  me  in  one  instant, 
and  some  day  I  will  not  be  able  to  resist  it.  It  seems  now  as 
if  there  was  a  galvanic  battery  up  from  your  floor  up  to  my 
brain  that  makes  my  head  feel  queer  and  tinghng.  Filthy 
words  and  bad  thoughts  shoot  into  my  mind,  too,  in  the  same 
way."     And  she  threw  herself  on  her  knees  in  an  agony  of 


STATES   OF  DEFECTIVE  INHIBITION.  339 

distress,  beseecliing  God  and  me  to  deliver  her  from  tHese 
homicidal  and  suicidal  impulses.  Yet  a  minute  before  she 
had  been  cheerful  and  laughing,  and  a  few  minutes  after  she 
was  the  same.  This  condition  passed  into  an  ordinary  attack 
of  melancholia,  from  which  she  recovered  in  due  time.  No 
doubt  the  theory  of  uncontrollable  impulse  is  liable  to  abuse, 
and  to  be  apphed  where  it  does  not  exist ;  but  one  might  as 
well  assume  that  there  is  no  real  epilepsy  because  malingerers 
and  hysterical  girls  simulate  fits,  or  that  there  is  no  such  con- 
dition as  hypnotism  because  rogues,  fools,  and  quacks  dabble 
in  deceit  and  call  it  mesmerism. 

Etiology. — The  states  of  defective  inhibition  and  impulse 
may  be  momentary  in  duration,  or  may  be  constant.  They 
may  be  slight  in  form,  or  most  intense.  Their  etiology  is  as 
varied  as  their  duration.  As  a  general  rule  they  are  met  with 
either  in  those  hereditarily  predisposed  to  the  neuroses,  or  in 
those  whose  normal  brain  functions  have  been  impaired  by 
over-indulgence  in  alcohol  or  nervous  stimuli  on  the  part  of 
themselves  or  their  parents.  In  some  few  cases  a  merely 
defective  training  of  the  brain  in  youth  seems  to  end  in  morbid 
hyperkinesia.  iNo  doubt,  if  Ave  could  devise  a  perfect  mode 
of  teaching  self-control  to  the  young  brain,  it  would  be  an 
educational  discovery,  the  most  valuable  yet  made  by  humanity. 
The  great  crises  of  life  sometimes  set  up  tliis  condition — 
puberty,  adolescence,  the  climacteric  period,  and  senility.  In 
many  cases  there  have  been  congenital  or  early  defects  of 
brain  development,  causing  volitional  and  moral  imbecility, 
or  what  Morel  called  instinctive  juvenile  mania.  Visceral 
derangements  and  reflex  irritations  are  the  causes  in  many 
cases.  Who  does  not  feel  his  volition  or  self-control 
sympathise  with  the  state  of  his  digestion  1  I  know  a  young 
woman  who,,  during  menstruation,  which  was  with  her  dif- 
ficult and  painful,  did  all  sorts  of  impulsive  acts — eat  dirt, 
hurt  herself,  and  pinch  children, — while  she  was  at  other 
times  amiable,  and  did  none  of  these  tilings.  There  is  no  doubt 
that  the  organic  instinct  of  reproduction  sometimes  becomes 


340  STATES   OF  DEFECTIVE  INHIBITION. 

transmuted  morbidly  into  instinctive  impulses  to  kill,  steal, 
&c. 

Varieties. — I  shall  confine  my  observations  to  the  commoner 
and  more  typical  varieties  of  morbid  impulse,  and  they  are 
the  following : — 

a.  General  Impulsiveness. 

b.  Epileptiform  Impulse.  . 

c.  Animal  and  Organic  Impulse. 

d.  Homicidal  Impulse. 

e.  Suicidal  Impidse. 

f.  Destructive  Impidse. 

g.  Dipsomania, 
h.  Kleptomania. 
i.  Pyromania. 

j.  Moral  Insanity. 

General  psychokinesia,  or  impulsiveness  in  all  directions,  is 
well  illustrated  in  the  following  case,  who  was  a  patient  of 
mine  in  Morningside  : — 

E.  T.,  set,  47,  of  a  very  neurotic  heredity,  a  brother 
being  insane  and  epileptic,  and  a  sister  insane.  In  addition 
to  this,  she  has  had  twenty  years  of  sorrow  and  domestic 
worry,  with  a  drunken  husband  who  could  not  provide  for 
her,  and  through  the  loss  of  several  of  her  children.  She  has 
had  ten  children  and  nine  or  ten  miscarriages.  The  children 
whom  she  lost  all  died  of  convulsions  or  hydrocephalus.  The 
excituig  cause  of  her  illness  was  an  abortion  at  two  months. 
She  was  very  impulsive  on  admission  in  all  ways.  She  tore 
her  clothes,  she  tried  to  jump  out  of  windoAvs,  she  refused 
food  at  times  when  she  did  not  get  what  she  wanted,  she 
would  do  any  mischief  that  was  in  her  j>ower.  Between  those 
acts  she  was  rational  in  speech  and  conduct,  affectionate,  and 
agreeable.  She  would  be  dancing,  lively,  and  chatty  in  the 
drawing-room,  apparently  one  of  the  happiest  women  there, 
and,  seeing  an  open  window,  she  would  suddenly  change  in 
expression  of  face  and  eyes,  would  step  towards  it,  and  try 
to  throw  herself  over.     When  asked  about  it  she  would  say 


STATES   OF  DEFECTIVE   INHIBITION.  341 

she  could  not  help  it.  She  was  always  most  impulsive  at  the 
menstrual  periods,  and  at  these  times  frequently  had  retention 
of  urine,  needing  the  catheter — this  she  had  been  subject  to 
occasionally  during  her  married  life.  The  bromides,  fattening 
non-stimulating  foods,  fresh  air,  baths,  and  constant  super- 
vision, discipline,  and  occupation  were  all  tried,  with  a  gradual 
good  effect.  The  impulses  became  less  intense,  and  her  self- 
control  more,  as  her  bodily  condition  improved.  She  was 
subject  to  sudden  feelings  of  what  she  described  as  "  unutter- 
able dread  and  woe,"  coming  like  a  flash  over  her  and  passing 
away  as  quickly.  Unfortunately,  at  first  we  gave  her  chloral 
and  hyoscyamus  at  night,  which  I  found  was  a  mistake.  She 
became  very  dependent  on  these  things  for  sleep.  She  did 
much  better  when  they  were  stopped.  !N"ow  I  never  give 
cliloral  for  long  where  there  is  impulsiveness.  I  believe  that 
its  effect  is  to  lessen  the  inhibitory  mental  power  of  the  brain. 
In  about  three  years  she  had  improved  considerably,  and  was 
removed  to  another  asylum,  and  ultimately,  after  ten  years, 
made  a  good  recovery.  It  must  be  remembered  that  all  these 
impulses,  obstinacies,  violences,  destructivenesses,  and  suicidal 
attempts  were  contrary  to  the  whole  habits  of  the  life  of  this 
lady  till  she  Avas  47 ;  that  they  then  lasted  more  or  less  for 
nine  years ;  and  that  between  those  acts  of  impulsiveness  she 
was  one  of  the  most  agreeable  and  sensible  persons  I  ever  saw, 
and  was  clever,  witty,  and  often  hilarious. 

The  next  case  was  a  very  striking  one,  and  was  well  described 
by  one  of  the  former  assistant  physicians  here,  Mr  James  Mac- 
laren}  I  look  on  it  as  being  generally  impulsive  and  to  some 
extent  mentally  epileptiform  in  character. 

"  Late  one  night  a  lady,  whom  we  shall  know  as  E.  U., 
was  brought  to  the  Royal  Edinburgh  Asylum,  labouring  under 
great  excitement,  and  bleeding  from  wounds  in  her  mouth 
caused  by  her  attempts  to  swallow  pieces  of  the  glass  of  a  cab 
window  which  she  had  broken.  Her  insanity  was  very  early 
seen  to  be  of  a  kind  in  which  the  leading  features  were 
^  Medical  Times  and  Gazette,  Janiiav}'  S,  1876. 


342  STATES   OF   DEFECTIVE   INHIBITION, 

impulsive  acts  of  a  sudden  and  a  most  dangerous  character  to 
herself  and  to  others.  She  is  not  an  epileptic ;  she  has  no 
definite  delusions  or  hallucinations.  In  her  the  paroxysm  of 
violence  has  the  following  characters : — It  is  periodic ;  it  is 
accompanied  by  always  partial,  frequently  total  unconscious- 
ness, and  consequently  followed  by  a  similar  state  of  f orget- 
fulness  of  her  acts ;  it  is  preceded  by  sharp  pain  in  the  head, 
and  followed  by  a  dull  pain  in  the  head,  dizziness,  and  con- 
fusion of  ideas.  There  exist  also  certain  neuroses,  but  these 
wUl  be  detailed  in  the  course  of  the  history  of  her  case,  which 
it  wUl  be  well  now  to  enter  on. 

"  She  is  forty -three  years  of  age,  the  fifth  child  of  a  family 
of  fourteen.  Her  parents  are  both  of  a  neurotic  type ;  her 
father  is  almost  totally  deaf,  and  a  brother  of  his  died  insane. 
Her  mother  dwells  on  the  border-land  of  insanity ;  she  was 
always  a  person  of  very  pecuKar  disposition,  suspicious, 
unreasonable,  and  of  an  exceedingly  high-strung  and  nervous 
temperament.  Tliis  was  her  condition  previous  to  marriage. 
Its  cares  and  troubles,  and  particularly  the  mental  and 
physical  wear  and  tear  involved  in  the  bearing  and  nursing 
of  fourteen  children,  told  badly  on  her.  Her  confinements 
were  severe,  and  after  them  she  was  subject  to  alarming 
floodings ;  at  her  menstrual  periods,  too,  the  haemorrhage 
was  always  excessive.  That  all  this  told  on  her  severely  was 
noticed  by  her  friends  in  her  increasing  debility,  nervousness, 
eccentricity,  and  irritability  as  she  advanced  in  years,  and,  to 
any  one  who  could  read  the  lesson,  was  confirmed  by  what 
seems  to  me  a  very  curious  fact.  She  had,  as  I  have  said, 
fourteen  children.  The  first  four  of  these  were  fairly  healthy, 
and  are  still  living ;  then  came  the  subject  of  the  present  note, 
regarding  whose  mental  and  physical  health  we  shall  presently 
hear ;  and  after  her  came  nine  cliildren,  all  of  whom  are  now 
dead.  The  elder  ones  lived  longest,  and  then,  as  the  mother 
grew  in  years,  and  the  strain  on  her  became  greater,  the 
duration  of  the  life  of  her  offspring  shortened.  It  is  true 
that  none  of  them  died  directly  from  brain  disease ;  still  it 


STATES  OF  DEFECTIVE  INHIBITION.  343 

does  not  seem  too  much,  to  assume,  with  the  history  I  have 
described,  that  the  parents  were  at  first  able  to  procreate 
healthy  offspring,  that  this  began  to  fail  with  E.  U.,  and  that 
after  her  the  strain  became  greater  and  greater,  and  so  they 
produced  children  only  in  the  poorest  degree  endowed  with 
the  power  of  living.  The  inverse  ratio  between  the  age  of 
the  parents  and  the  duration  of  life  in  the  offspring  seems  too 
marked  and  definite  to  be  due  to  accident  or  chance.  So, 
then,  in  this  neurotic  couple  we  have  them  in  their  early 
married  life  transmitting  to  their  children  health,  later  on 
insanity,  and  ultimately  a  tendency  to  early  death. 

"  And  here,  forestalling  its  position  in  the  history  of  her 
case,  comes  in  another  step  in  the  descent  and  progressive 
degeneration,  E.  U.  has  become  pregnant  several  times : 
one  child  is  alive,  one  lived  a  few  months,  all  the  rest  were 
born  prematurely.  The  child  which  is  ahve  is,  as  regards 
his  mind  at  present,  precocious  and  talented,  writes  letters 
in  a  style  beyond  his  years,  reads  books  on  natural  science, 
and  is  fond  of  sketching  and  painting,  and  thought  exceed- 
ingly gifted  by  his  friends.  He  was  stunted  in  body,  weak 
and  miserable  when  young,  and  often  barely  kept  alive  by 
constant  and  most  careful  nursing,  but  developed  into  a 
strong-looking  lad; 

"I  have  now  to  speak  of  the  personal  history  and  charac- 
teristics of  the  unfortunate  lady  who  is  the  subject  of  this 
sketch.  As  I  have  said,  she  was  the  fifth  child  of  her  parents. 
In  her  early  years  she  was  only  noted  for  everything  that 
was  good  and  amiable.  In  tliis  I  am  not  taking  the  words  of 
possibly  too  partial  friends,  but  of  others  who  knew  her  more 
or  less  intimately ;  and  one  and  all  bear  testimony  to  the  fact 
that,  as  regards  the  possession  of  many  good  quahties,  she 
was  far  above  the  average.  Kind  and  loving,  very  gentle  and 
quiet,  but  apt  to  become  emotional  on  trifling  provocation ; 
devoted  as  far  as  her  strength  permitted  to  all  good  works, 
generous  even  to  a  fault,  and  earnest  in  season  and  out  of 
season  to  do  her  duty, — such  is  the  account  of -her  in  her  early 


344  STATES   OF   defective' INHIBITION. 

days.  From  her  earliest  years  religion  was  part  of  lier  daily  life, 
not  engrafted  on  to  her  other  duties,  "but  forming  the  moving 
principle  of  all  she  did.  She  belonged  to  a  devout  family  and 
an  earnest  sect ;  and  so,  by  education  as  "svell  as  temperament, 
was  thoroughly  and  entirely  devoted  to  sacred  thoughts  and 
duties,  and  was  noted  among  her  friends  for  the  emotional 
fervour  and  power  of  her  prayers.  In  ahihty,  too,  she  was 
ahove  the  average — clever,  studious,  and  painstaking. 

"At  the  age  of  twenty -three  she  married  her  present 
husband — a  gentleman  in  every  way  calculated  to  make  her 
happy.  It  was  long  before  he  noticed  anything  particularly 
strange  in  her  manner  or  conduct.  Certain  sHght  pecuharities, 
a  morbid  sensitiveness  as  to  possible  wrong-doing,  occasionally 
excessive  emotionahsm ;  and  once  or  twice,  when  in  circum- 
stances calculated  to  excite  or  distress  her  (such  as  being 
in  the  company  of  uncongenial  people  or  those  of  a  liigher 
social  rank),  a  tendency  to  become  rambling  and  incoherent, 
-^these  were,  as  far  as  he  can  remember,  the  only  facts 
that  called  for  notice  or  excited  alarm.  Still  they  were  of 
the  shghtest. 

"Some  years  after  she  was  married,  and  ten  years  ago, 
the  boy  already  mentioned  was  born,  but  previous  to  that,  and 
since,  she  had  several  times  aborted.  On  each  occasion  her 
bodily  weakness  from  excessive  flooding  was  great,  and  her  men- 
tal distress  at  the  unfortunate  issue  very  painful.  Two  years 
ago  she  again  becaane  pregnant,  and,  greatly  to  her  joy,  was 
dehvered  of  an  apparently  healthy  boy,  and  for  a  Httle  while 
the  caring  for  it  seemed  to  restore  the  balance  of  her  mind. 
However,  it  was  only  spared  to  her  for  a  few  months,  and 
its  death  and  the  final  and  marked  access  of  her  insanity 
followed  each  other.  During  her  pregnancy,  and  for  some 
months  before,  the  httle  abnormalities  I  have  mentioned 
were  beginning  to  be  more  and  more  marked.  Her  rehgi- 
ous  feehngs  became  of  the  most  exalted  character,  and  her 
emotionahsm  excessive.  On  one  occasion,  while  walking 
Avith  her  husband  in  a  frequented  place,   she  knelt   down 


STATES   OF   DEFECTIVE  INHIBITION.  345 

and  prayed  for  strength  to  bear  her  coming  trial;  and  her 
benevolence  and  generosity,  always  prominent  features  in 
her  character,  became  almost  unbounded  and  frequently 
quite  unreasonable.  When  the  baby  came,  her  attention  was 
taken  up  with  it,  to  the  exclusion  of  everything  and  every 
one  else.  Then  it  was  taken  away,  and  from  that  time  is 
dated  the  marked  unmistakable  arrival  of  the  insanity. 
General  excitement,  an  altogether  morbid  and  excessive  fear 
regarding  her  religious  state  and  future  salvation,  and  an  ex- 
cessive sensitiveness  as  to  the  possibility  of  ever  having  in  any 
way  wronged  any  one  with  whom  she  might  have  had  deal- 
ings, were  the  early  symptoms  she  displayed.  Then  sudden 
and  unaccountable  outbreaks  of  dangerous  violence,  attempts 
at  self-destruction  occasionally,  and  most  destructive  ten- 
dencies in  every  respect,  rendered  her  removal  to  an  asylum 
imperative.  She  was  accordingly  taken  to  a  private  estab- 
hshment,  where  she  remained  for  a  few  months,  gradually 
getting  worse  and  worse.  During  tliis  time  an  haematoma 
of  the  left  ear  developed  itself,  and  ran  the  usual  course, 
leading  to  the  shrivelled  and  characteristic  insane  ear. 

"First,  as  to  her  appearance — she  is  sHght  and  almost 
undersized,  a  very  gentle-looking  lady,  with  a  pale,  pretty  face, 
light  hair,  and  blue  eyes,  a  singularly  kind,  pleasant,  winning 
manner,  and  a  soft,  quiet  voice.  Second,  as  to  her  mental 
state — free  from  excitement,  she  is  what  she  has  aheady  been 
described  as,  thoroughly  devout  and  good.  Her  memory  and 
judgment  are  in  all  but  one  respect  correct.  Thoughts  of  her 
husband  and  child,  bitter  regret  at  her  separation  from  them 
and  at  her  sad  calamity,  a  constant  and  prevailing  desire  to  do 
what  is  right,  and  an  excessive  and  morbid  sensitiveness  lest 
her  slightest  word,  or  look,  or  action  may  be  in  any  way  wrong. 
That  is  the  bright  side  of  the  picture  of  a  singularly  pure  but 
sadly  imperfect  nature.     'Now  for  the  reverse. 

"It  is  difficult  in  a  pen-and-ink  sketch  to  give  an  idea  of 
the  intense  impulsiveness  of  her  acts.  She  will  sit  reading 
her  Bible  or  some  good  book,  or  talking  in  her  quiet,  gentle 


346  STATES   OF   DEFECTIVE  INHIBITION. 

way  to  her  attendant,  when  suddenly,  without  a  moment's 
warning,  the  hook  is  flung  through  the  nearest  window,  or  at 
whatever  is  breakahle  at  hand,  then  she  makes  a  rush  to  run 
her  head  into  the  fire,  or  turns  on  her  attendant,  tears  her 
clothes,  or  tries  to  strangle  her.  All  this  without  speaking  a 
AN^ord,  except  perhaps  an  occasional  muttered  text  of  Scrip- 
ture ;  hut  beyond  that,  she  keeps  quite  silent,  and  struggles 
on  quietly  but  fiercely,  till  either  exhausted,  or  restored  by 
some  apparent  process  of  awakening  to  her  former  condition. 
Excitement,  of  course,  there  is  in  plenty,  but  it  is  very  different 
from  that  associated  with  more  ordinary  forms  of  mania. 
There  is  no  noise  or  shouting;  her  eyes  are  fixed  and  suffused, 
her  face  flushed,  and  her  teeth  clenched,  and  every  muscle  is 
on  the  strain ;  but  the  whole  time  she  is  perfectly  quiet,  and 
struggles  on  with  a  fixed  determined  purpose  expressed  in  her 
whole  manner,  but  without  wasting  a  word.  There  is  hardly 
a  method  of  attempting  violence  that  the  mind  could  conceive 
that  she  has  not  had  recourse  to.  At  one  time,  but  only  for 
a  few  weeks,  her  acts  took  the  form  of  exposure  of  her  person, 
and  in  this,  too,  suddenness  was  the  marked  feature.  I  have 
seen  her  weeping  bitterly  at  the  sadness  of  her  lot,  and  praying 
for  some  help,  and  while  the  words  were  still  on  her  hps, 
throw  herself  on  the  ground,  and  piill  up  her  dress.  Once  or 
twice  about  this  time  there  was  a  sKght  increase  of  her  general 
excitement,  and  she  laughed  and  talked  more  than  usual ;  but 
as  a  rule  the  exposure  was  something  altogether  different  from 
the  ordinary  suggestive  act  of  an  erotic  female.  This  tendency 
to  exposure,  however,  did  not  last  long,  and  has  not  returned. 
"Now,  as  to  the  nature  of  her  paroxysms.  Though  not 
very  definite,  there  is  no  doubt  that  there  is  a  certain  amount 
of  periodicity  in  them.  It  is  not  hard  and  fast,  but  her 
attendants  notice  that  she  has,  as  they  put  it,  a  good  day  and 
a  bad  one,  or  two  good  days  and  two  bad  ones.  Then — and 
tliis  seems  to  me  a  very  important  point  in  her  history — there 
is,  as  a  rule,  entire  unconsciousness  and  forgetfulness  of  what 
passed  during  an  attack,     I  have  often  taken  her  carefully 


STATES   OF   DEFECTIVE   INHIBITION.  347 

over  the  events  of  a  day  in  which  one  had  occurred,  and 
invariably  found  her  correct  and  precise  in  every  detail  tUl 
we  reached  the  onset  of  the  seizure.  Then  all  was  a  blank, 
and  she  only  remembered  that  she  seemed  to  faint,  and  then 
found  herself  lying  on  a  sofa  with  an  acliing  head,  and  con- 
fused and  stupid.  Occasionally,  and  if  her  seizure  has  not 
been  very  severe,  she  has  some  slight  recollection  of  her  act 
and  of  the  impulse  which  led  to  it,  and  the  latter  is  always  a 
feehng  of  imperative  necessity  that  it  is  her  duty  to  do  as  she 
has  done ;  but  in  by  far  the  greater  number  of  her  attacks  un- 
consciousness during  and  after  was  the  rule. 

"  There  are  a  few  physical  phenomena  connected  with  her 
case  that  I  will  now  mention.  The  insane  ear  has  already 
been  recorded.  Her  tongue  is  tremulous,  and  points  markedly 
to  the  right  side.  After  an  attack  she  has  a  slight  stutter  and 
thickness  of  speech.  The  right  pupil  is  more  dilated  than  the 
left.  During  a  paroxysm  both  pupils  dilate  and  contract  con- 
stantly and  independently  of  each  other,  so  that  sometimes 
one  and  sometimes  the  other  is  the  more  dilated.  Her  hair  is 
exceedingly  dry ;  her  temperature  is  normal,  with  a  steady 
increase  of  two  points  in  the  evening  over  the  morning  figure. 
Her  menstruation  has  not  returned  since  her  last  chUd  was  born. 
Her  sensibility  is  at  all  times  dulled ;  during  an  attack  it  is 
greatly  impaired.     The  reflex  action  of  the  cord  is  much  dulled. 

"  What  is  the  nature  of  her  insanity  ?  Her  attacks,  read 
alone,  seem  only  to  want  one  factor — epilepsy — to  make  all 
complete.  This,  though,  is  wanting  ;  she  is  not  epileptic  now, 
and  has  never  been  so. 

"  It  is  a  strange  condition  of  dual  consciousness.  Whether 
she  remembers  in  each  paroxysm  what  happened  in  the  last  I 
cannot  say,  but  I  think  she  does,  and  it  is  certain  that  she 
follows  out  trains  of  thoughts  in  successive  attacks  of  which 
she  has  no  consciousness  during  a  remission.  For  instance, 
of  late,  as  soon  as  a  seizure  comes  on  her,  she  makes  particular 
efforts  to  get  at  one  special  picture  in  the  room.  When  the 
attack  has  passed,  this  picture  awakens  no  feelings  in  her  at  all, 


348  STATES  OF  DEFECTIVE   INHIBITION. 

and  she  has  no  recollection  of  anything  particular  connected 
with  it ;  but  as  soon  as  the  excitement  returns,  her  attention 
fixes  on  it  at  once." 

In  the  course  of  three  years  she  gradually  became  less 
dangerous  and  the  impulsive  attacks  less  intense,  wliile  her 
mind  became  more  enfeebled.  She  got  so  much  better  that 
she  was  taken  home  under  the  charge  of  a  nurse,  seemed  to 
be  almost  demented,  and  quite  incurable.  The  impulsiveness 
seemed  to  have  disappeared,  but  after  nine  years  she  suddenly 
committed  suicide. 

Einleptiform  Impulse. — Epilepsy,  as  we  shaU.  see  in  the 
psychosis  commonly  associated  with  it  (epileptic  insanity), 
tends  remarkably  towards  impulsive  acts,  which  will  be 
considered  under  that  form  of  insanity.  By  epileptiform 
impulse  I  mean  those  sudden  impulsive  acts,  attended  by 
unconsciousness,  which  are  exactly  the  same  in  character  as 
those  we  are  familiar  with  in  epileptics,  and  yet  the  patients 
are  not  subject  to  ordinary  epilepsy.  Some  of  the  acts  of  the 
last  case,  E.  U.,  were  clearly  of  this  character.  I  have  now 
a  patient  who  brought  on  his  disease  by  over-drinking,  and 
who  on  one  occasion  leaped  through  a  window  on  the  third 
story  when  quite  sober,  and  did  not  know  anything  about  it 
afterwards.  On  another  occasion,  in  passing  the  corner  of  a 
building  in  the  Asylum,  he  ran  violently  against  it  with  his 
head,  causing  a  wound  five  inches  long,  and  very  nearly 
breaking  his  skuU-cap.  He  is  not  a  regular  epileptic,  but  he 
once  took  a  convulsive  epileptiform  attack.  His  case  is 
incurable,  he  is  now  getting  partially  demented,  and  his 
impulsiveness  is  passing  ofi".  The  regular  use  of  the  bromide 
of  potassium  seemed  to  diminish  the  impulsive  tendency. 

Animal  and  Organic  Impulse. — Under  this  term  I  include  all 
the  uncontrollable  impulses  towards  sexual  intercourse,  mastur- 
bation, sodomy,  rape  on  children,  bestiality,  &c.  The  per- 
verted instincts,  appetites,  and  feelings  shown  in  urine 
drinking,  eating  stones,  rags,  clay,  nails,  &c.,  come  under  this 
heading  too.     There  are  few  cases  of  mental  disease  where 


STATES  OF  DEFECTIVE   INHIBITION.  349 

some  appetite  or  instinct  is  not  in  some  degree  perverted  or 
paralysed.  But  tliere  are  cases  where  such  things  are  so 
prominent  as  to  constitute  the  disease.  I  have  a  patient  who 
assures  me  that  his  desire  to  masturbate  is  an  irresistible 
craving,  which  he  has  no  power  to  control.  Here  is  a  girl 
who  rubs  her  thighs  together  to  produce  sexual  excitement 
the  moment  she  sees  a  man.  Here  is  a  case  of  nymphomania, 
who  rushes  towards  any  man  she  sees,  and  can  scarcely  be 
held  by  two  attendants.  The  cases  of  "  contrary  sexual 
instinct"  ("  Timings ")  to  whom  I  have  referred  (p.  277) 
frequently  show  insane  loss  of  control.  I  believe  there  are 
cases  in  which  there  are  irresistible  impulses  towards  sodomy 
and  incest.  Many  of  the  men  who  commit  rape  on  cliildren 
are  insane.  I  lately  had  to  give  evidence  at  the  Carlisle 
Assizes  about  the  insanity  of  a  medical  man  who  had  tried 
to  commit  rape  on  three  cliildren  under  age  in  succession. 
Ho  doubt  he  had  the  delusion  that  God  had  in  some  occult 
way  revealed  to  him  that  he  should  beget  a  male  child,  and 
had  sent  the  Httle  girls  to  him  for  this  purpose;  but  he 
was  practising  his  profession  up  to  the'  commission  of  the 
act.  "  I  have  referred  to  the  case  of  the  young  woman  who 
had  an  impulse  to  eat  clay  and  dirt  every  time  she  menstru- 
ated. She  could  not  help  it,  and  had  no  such  tendency 
between.  A  shoemaker  patient  in  the  Prestwich  Asylum 
swallowed  a  few  shoe-nails  every  day,  and,  what  was  strange, 
was  none  the  worse.  There  is  an  infinite  variety  of  such 
impulses.  Erotomania  is  a  term  applied  to  those  cases  where 
there  is  an  intensely  morbid  desire  towards  a  person  of  the 
opposite  sex,  without  reference  to  the  sexual  act.  It  is  a  sort 
of  exaggerated  and  insane  state  of   "  being  in  love." 

Homicidal^  Impulse. — Homicidal  impulse  is  often  spoken  of 
by  lawyers,  publicists,  and  ignorant  persons  as  if  it  were  a 
thing  that  did  not  really  exist,  but  has  been  set  up  by  the 
doctors  to  enable  real  criminals  to  escape  justice.  Here  is  a 
letter  from  a  former  patient  of  mine,  E.  Y.,  a  medical  man 
of  truthfulness  and  great  benevolence  of  character,  written  to 


350  STATES   OF  DEFECTIVE  INHIBITION. 

me  wlien  he  was  convalescent,  exliibiting  vividly  homiqiclal 
impulse  : — 

My  Deak  Sir, — According  to  promise  I  have  written  to  the  best  of 
my  ability  what  I  feel  mentally.  God  alone  knows  my  feelings.  They 
are  truly  awful  to  know.  I  lived  in  continual  fear  of  doing  harm  each 
day.  I  had  not  a  moment's  peace  in  this  world.  I  have  been  in  prac- 
tice for  twenty-three  years,  and  have  attended  2550  midwifery  cases, 
which  used  to  take  the  life  out  of  me  more  than  anything  else.  I  often 
used,  when  busy,  to  attend  60  or  70  patients  a  day  at  home  and  out, 
and  in  the  winter  used  to  average  28  a  day  at  their  houses.  I  have  had 
no  holiday  for  many  years.  I  did  not  think  I  was  laying  the  seeds  of 
brain  disease,  but  such  has  been  the  case  in  the  most  dreadful  form. 
I  loved  my  dearest  wife  and  little  ones  most  dearly,  and  my  home  used 
to  be  so  happy  and  cheerful  after  my  hard  work.  You  are  aware  I  had 
a  very  long  illness  in  bed,  had  several  operations,  erysipelas,  &c.  Two 
years  previous  to  this  I  had  a  fall  on  my  head,  which  stunned  me  at  the 
time.  I  may  say  I  have  never  felt  really  well  since  the  fall,  though  I 
did  my  practice.  I  had  occasional  strange  feelings,  but  those  were  only 
known  to  myself,  being  ashamed  to  mention  them  ;  in  fact,  all  the  time, 
up  to  within  a  short  time  of  coming  under  your  care,  I  appeared  cheerful 
and  even  jolly.  But  when  in  a  train  I  was  afraid  I  should  jump  out  of 
the  window,  and  when  I  saw  one  in  motion  I  felt  I  must  jump  under  it. 
I  was  afraid,  when  appljdng  nitrate  of  silver  to  the  throats  of  my  patients, 
that  I  should  push  it  down.  I  was  terrified  to  apply  the  midwifery 
forceps,  lest  I  should  not  be  able  to  resist  the  impulses  I  had  to  drive 
them  up  through  the  patient's  body.  When  opening  abscesses  I  felt  as 
if  I  must  push  the  knife  in  as  far  as  possible.  When  I  sat  down  at  my 
own  table  I  used  to  have  horrible  impulses  to  cut  my  children's  throats 
with  the  carving  knife.  At  the  sight  of  pins  I  had  a  feeling  as  if  some 
had  got  into  my  throat,  and  I  could  not  divest  myself  for  some  time  of 
this  feeling.  I  had  other  strange  feelings  which  I  can  hardly  describe. 
Whenever  I  saw  a  knife,  razor,  gun,  &c.,  I  was  afraid  I  should  do  harm 
by  a  sudden  impulse,  the  will  having  hardly  the  power  to  resist.  I  took 
opium  several  times  from  no  deliberate  intention  but  by  a  sudden  impulse 
that  I  could  not  resist  when  I  was  working  with  it  in  the  surgery,  but  I 
vomited  it. 

My  brain  feels  quite  dead,  with  no  feeling  in  the  scalp  ;  my  eyes  seem 
as  if  something  were  dragging  at  the  optic  nerve  continually.  In  the 
left  I  have  a  most  unpleasant  feeling  to  bear,  and  I  cannot  see  distinctly 
with  it.  There  appears  to  be  something  floating  in  front  all  the  time, 
tike  a  dark  shade.  I  should  say  I  am,  and  have  been,  suffering  from 
homicidal  monomania  and  moral  insanity,  and  have  been  since  June 
last,  although  a  part  of  the  time  doing  my  practice  and  living  with  my 
family.  I  thought  I  could  shake  it  off',  but  such  was  unfortunately  not 
the  case. 


STATES   OF   DEFECTIVE   INHIBITION,  351 

Thanking  you  most  sincerely  for  the  kindness  and  attention  shown  to 
me  since  I  have  been  a  patient  in  this  Asylum,  I  am,  dear  sir,  yours 
faithfully,  E.  V. 

iN'ow,  this  is  either  a  tissue  of  lies,  or  the  thing  "homicidal 
impulse  "  exists.  This  unfortunate  man  had  placed  himself 
in  the  Asylum  of  his  own  accord,  and  he  took  a  gloomy  view 
of  liis  prospects  of  recovery.  I  did  not  do  so,  but  assured 
him  he  would  recover,  and  adopted  every  means  for  that 
purpose ;  gave  him  tonics,  got  him  employed  and  interested, 
made  him  live  in  the  fresh  air,  and  go  to  all  sorts  of  amuse- 
ments in  the  Asylum  and  out  of  it.  I  am  glad  to  say  he 
recovered,  and  went  into  practice,  and  unfortunately  got  as 
much  to  do  as  ever,  and  relapsed.  This  time  he  showed  his 
impulsive  tendency  and  loss  of  inhibition  by  taking  to  drink, 
which  looked  Hke  a  symptom  of  his  brain  disorder.  By 
temperament  he  was  a  sanguine  man,  strong,  hearty,  robust, 
and  jolly.  In  fact,  he  was  a  perfect  Mark  Tapley  in  his 
unfaHing  cheerfulness  under  difficulties  and  disasters.  He 
was  an  immense  favourite  with  the  ladies  here,  and  to  see 
"  the  doctor  "  being  taught  by  them  to  dance  a  Scotch  reel 
was  a  sight  far  away  from  any  suicidal  or  homicidal  idea. 
Yet  in  the  midst  of  this  a  dark  shadow  would  sometimes 
cross  his  face,  and  he  would  say  to  me,  "  Oh,  doctor,  these 
strange  feelings;  if  they  would  only  keep  away  I  should  be 
as  happy  as  I  look." 

This  is  merely  one  case,  but  it  is  a  typical  one.  E.  Y.  had 
no  insane  delusions — he  could  reason  well ;  affectively  he  was 
fond  of  his  wife  and  family  and  friends ;  he  had  not  a  cruel 
or  criminal  disposition — quite  the  reverse ;  he  had  no  outward 
excitement,  no  signs  of  outward  depression  hke  an  ordinary 
melancholic  patient ;  he  had  no  "  motive  "  to  do  so,  yet  he 
wanted  to  kill  his  patients  and  his  children,  and  had  much 
difficulty  in  restraining  liimself  from  doing  so,  and  he  actually 
could  not  restrain  himself  from  suicidal  acts.  All  these 
feehngs  were  connected  with  an  original  heredity  to  mental 
disease,  with  a  brain  injured  by  the  fall,  and  exhausted  by 


352  STATES   OF   DEFECTIVE   INHIBITION. 

liard  work  and  insufficient  rest,  and  with  a  running  down  of 
his  general  vital  power  by  the  bodily  disease  he  had  lately 
suffered  from.  They  had  as  their  accompaniments  those 
marked  sensory  and  special  sense  feelings  described  in  his 
letter,  which  were  really  essential  parts  of  his  trouble.  They 
disappeared  under  rest,  change,  proper  medical  and  moral 
treatment.  The  whole  affection  was  just  like  many  other 
diseases  in  its  causation,  inception,  and  recovery.  What 
room,  therefore,  is  there  for  doubt  that  such  a  disease  exists  1 
That  the  theory  of  uncontrollable  homicidal  impulse  should 
have  been  used  in  courts  of  justice  to  -screen  real  murderers 
or  would-be  murderers  is  surely  no  reason  for  disbelieving 
important  facts  of  disease.  It  is  our  duty  as  medical  men  to 
examine  carefully  the  evidence  in  every  case  where  a  homi- 
cidal impulse  theory  is  set  up  to  explain  crime,  to  look  on 
any  such  case  suspiciously  perhaps,  to  search  for  other 
symptoms  and  causes  of  mental  or  nervous  disease  accom- 
panying it,  but  we  must  not  be  frightened  into  bhnking  real 
facts  and  real  disease.  An  admirable  example  of  homicidal 
impulse  was  described  by  Dr  Elkins  in  the  Edinburgh  Medical 
Journal  for  September  1890.  It  is  weU  worth  study.  The 
f oUowing  was  a  striking  case  of  the  same  sort : — Joseph  Eed- 
mond,  set.  49.  Had  been  in  the  army  in  India,  and  while 
there  drank  hard,  had  sunstroke  and  syphilis,  and  he  since 
could  never  stand  alcohol.  He  came  home,  married,  kept  a 
shop,  and  made  money.  He  Hved  comfortably  and  happily 
with  his  wife,  who  was  a  sober,  well-conducted  woman.  He 
was  subject  to  "  fits  of  passion,"  during  which  he  did  not 
know  what  he  was  doing.  He  was  also  suspicious,  and  seems 
to  have  had  hallucinations  of  hearing  in  the  shape  of  "voices," 
wliich  ;were  those  of  old  friends,  telling  him  to  do  certain 
things.  Wlien  he  got  "a  glass,"  which  he  rarely  did,  he 
seems  to  have  become  dangerously  homicidal.  In  one-  of 
those  conditions  he  stabbed  his  wife.  When  he  came  to  him- 
self he  had  no  recollection  of  what  he  had  done,  and  was 
horrified  and  dejected.     He  was  sent  first  to  the  Asylum  to 


STATES   OF   DEFECTIVE   INHIBITION.  353 

await  his  trial;  while  there  he  would  certainly  .have  com- 
mitted suicide  from  pure  grief  and  remorse  had  he  not  been 
constantly  watched.  He  only  slept  after  getting  3iss.  of 
paraldehyde,  but  was  quiet  in  conduct  and  quite  rational, 
except  that  he  still  heard  the  "voices."  He  was  sent  to  the 
lunatic  department  of  Perth  Prison  "during  Her  Majesty's 
pleasure."  I  had  no  doubt  that  the  sunstroke  and  drink 
together  in  India  had  caused  damage  to  his  brain  cortex. 

Homicidal  impulses  in  a  mild  way  are  very  common  indeed 
in  the  beginning  of  mania  and  melanchoha.  Patients  feel  as 
if  they  must  kick  and  strike  those  near  them,  and  they  often 
do  so.  It  is  a  relief  to  them  to  do  so.  Such  impulses  are 
often  part  of  the  nervous  disturbances  that  accompany 
puberty,  disordered  menstruation,  childbirth,  lactation,  and 
the  climacteric  period  in  women.  I  once  saw  in  gaol  a  girl 
of  thirteen,  whom  I  had  no  doubt  had  without  motive  killed 
a  child  entrusted  to  her  care,  though  there  was  no  legal  proof 
of  it.  Margaret  Messenger,  a  little  girl  of  thirteen,  was 
proved  at  the  Carlisle  Assizes,  1881,  to  have  drowned  a  child 
of  six  months,  of  which  she  had  charge,  and  she  had 
previously  killed  its  brother.  Like  all  such  cases,  she  had 
no  motive,  and  showed  no  mental  excitement  nor  depression. 
She  could  not  be  made  to  realise  the  gravity  of  her  situation 
nor  the  awful  nature  of  the  crime  she  had  committed.  This 
paralysis  of  feeling  and  of  fear  is  very  characteristic  of  such 
cases.  She  was  described  as  a  "typical  country  girl  of  her 
age,  fresh,  tidy-looking,  and  fairly  intelligent."  She  was 
quite  composed  through  the  trial.  After  her  conviction  she 
confessed  that  she  had  killed  the  brother  by  throwing  him 
into  a  well,  into  which  it  had  been  supposed  he  had  fallen 
accidentally.  I  once  had  a  patient,  E.  Y.  A.,  a  lady  with  a 
child  five  months  old  when  I  saw  her,  and  who,  on  medical 
advice,  left  her  home  on  account  of  a  morbid  dislike  to  her 
husband  and  child,  and  homicidal  impulses  towards  them. 
During  her  pregnancy  she  had  the  same  kind  of  dislike  to 
her  mother.     She  deplored  these  morbid  desires  to  kill  her 

z 


354  STATES   OF  DEFECTIVE  IXHIBITION. 

husband  and  child  intensely,  because  she  was  devoted  to 
them,  and  a  very  affectionate  woman.  She  had  suicidal 
impulses  too,  but  not  so  strong.  These  were  not  the  only 
symptoms  of  disease.  She  suffered  from  dull  headaches, 
twitchings  on  the  right  side  of  her  face  when  she  spoke,  im- 
paired sleep,  fever,  slight  albuminuria,  aggravation  of  all  her 
symptoms  in  the  mornings,  screaming  fits,  want  of  appetite, 
thinness,  and  a  pigmented  skin.  Through  change,  absence 
from  home,  milk  diet,  exercise  in  the  fresh  air,  iron,  claret, 
and  pleasant  companionship  and  travel,  she  recovered  in 
about  four  months,  getting  stout,  fresh-coloured,'  and  men- 
struation becoming  regular.  I  have  referred  to  the  case  of 
B.  E.  (p.  116),  a  cHmacteric  case,  and  her  tendency  to  kick, 
strike,  and  pinch  her  fellow-patients  in  the  morning  only, 
while  in  the  evenings  she  would  be  cheerful,  would  dance, 
and  enjoy  herself.  I  had  lately  a  man,  E.  V.  B.,  with  a 
neurotic  heredity,  an  uncle  being  epileptic,  who,  when  sitting 
at  a  window,  dropped  a  big  stone  on  to  the  top  of  the  head 
of  a  casual  passer-by,  against  whom  he  had  no  ill-feeling 
whatever.  After  he  was  sent  to  the  Asylum  we  could  see 
nothing  Avrong  with  him  till  one  day  he  tried  to  stick  a  dung- 
fork  into  an  attendant.  He  seemed  to  recover,  and,  after  a 
long  time  of  probation,  he  was  discharged,  but  very  soon  ran 
after  a  relation  with  an  open  knife.  He  was  sent  back  to 
the  Asylum,  showed  no  signs  of  insanity  at  first,  and  then  his 
mind  gradually  became  enfeebled,  and  he  is  now  nearly  de- 
mented, just  as  he  would  have  become  had  his  attack  been  one 
of  mania,  Homicidal  impulse  is  thus  seen  to  end  in  dementia 
if  it  lasts  long,  hke  any  other  kind  of  mental  disease.  I  have 
seen  a  homicidal  stage  in  the  beginning  of  general  paralysis. 

Suicidal  Impulse. — I  am  speaking  here,  remember,  of 
suicide  as  an  ivipidse  unaccompanied  hy  any  marked  mental 
depression  or  delusion.  The  folloioing  two  cases  exemplify 
ivJiat  I  mean  : — 

E.  "W".,  a  young  man  of  18,  of  nervous  heredity,  with  no 
particular  cause  of  mental  or  bodily  disturbance,  except  per- 


STATES   OF  DEFECTIVE   INHIBITION.  355 

haps  an  unrequited  love  fancy  for  the  scuUery-maid.  He, 
being  an  assistant  to  a  butler  in  a  gentleman's  family  in 
Cumberland,  seemed  in  good  health,  in  good  spirits,  and  Avas 
"washing  the  dishes  after  lunch  one  Sunday.  His  master, 
from  the  dining-room,  heard  a  pecuHar  sound  in  the  pantry, 
and,  going  to  see  what  it  was,  found  E.  W.  hanging  by  the 
towel  with  which  he  had  been  wiping  his  dishes,  his  face 
livid,  and  nearly  dead.  After  being  taken  down  he  was  un- 
conscious for  some  hours,  and  was  then  confused  in  mind 
for  a  day  or  two.  He  was  sent  next  day  to  my  care  at  the 
Carlisle  Asylum,  and  I  found  him  confused,  and  his  memory 
defective.  He  could  give  no  account  whatever  of  the  suicidal 
attempt,  and  was  rather  inclined  to  deny  it,  but  the  evidences 
of  it  were  well  marked  on  his  neck  and  face.  There  was  no 
mental  pain  and  no  delusion.  He  did  not  sleep  very  well. 
He  was  sent  much  into  the  open  air,  and  was  ordered  a  little 
bromide  of  potassium.  In  a  week  there  was  not  a  trace  of 
any  mental  defect  whatever.  He  was  not  a  strong-minded 
youth,  but  was  not  imbecile.  He  maintained  through  many 
cross-questionings  that  he  never  had  a  conscious  intention 
or  thought  of  putting  an  end  to  liimself  in  his  life ;  that  he 
remembered  events  quite  well  up  to  a  certain  moment  on  the 
Sunday  he  was  washing  his  dishes,  but  after  that  he  had  no 
recollection  of  anything  whatever  till  the  evening.  I  had  no 
reason  whatever  to  doubt  the  correctness  of  his  statements 
which  were  confirmed  by  the  butler.  He  kept  quite  well 
when  last  I  heard  of  him. 

E.  X.,  a  young  professional  man  of  30,  whose  father  had 
been  subject  to  "depression  of  spirits,"  and  who  had  had 
chorea  in  his  youth,  but  Avho  was  clever,  cheerful,  good- 
principled,  reHgious,  and  successful.  He  Avas  happily  engaged 
to  have  been  married  in  a  fortnight.  He  had  been  spending 
the  evening  with  some  friends,  and  was  in  first-rate  spirits. 
'No  melancholy  nor  morbidness  whatever  had  been  seen  in 
him.  He  had  remarked  to  some  friend  casually  some  weeks 
before  that  he  had  to  hold  his  head  in  a  particular  way  or 


oo6  STATES   OF   DEFECTIVE  INHIBITION. 

he  saw  tilings  double.  He  took  a  hearty  supper,  and  went 
to  his  bedroom.  In  the  morning  his  body  was  found 
suspended  to  a  cupboard  door  by  the  worsted  cord  of  the 
window  curtain.  He  had  undressed,  and  then,  evidently 
without  preparation  or  contrivance  of  any  kind,  taken  the 
cord,  which  was  sewn  in  a  circle,  thrown  it  as  a  loop  over  the 
top  of  the  half-open  door,  put  the  other  end  of  the  loop  under 
his  chin,  and,  pulling  up  his  feet,  suspended  himself.  There 
was  a  strong  presumption  that  it  was  not  a  conscious  pre- 
meditated act.  We  found  a  large  ossified  spiculum  of  bone 
projecting  from  the  dura  mater  into  a  convolution  at  tbe 
vertex  at  the  junction  of  the  anterior  with  the  middle  lobe, 
the  arachnoid  thickened,  and  the  whole  brain  intensely  con- 
gested. I  considered  the  case  one  of  unconscious  suicidal 
impulse  of  an  epileptiform  nature.  Such  irritating  spicula  of 
bone  of  course  often  cause  ordinary  epilepsy,  and  this  is  not 
the  only  case  of  impulsive  insanity  in  which  after  death  I 
have  met  with  the  same  pathological  appearances. 

Those  were  cases  of  morbid  suicidal  impulses  accompanied 
by  unconsciousness.  Such  cases  'are  rare.  But  cases  lolio  are 
quite  conscious  like  the  folloiving  are  very  common. 

E.  X.  A.,  a  man  of  55,  who  had  been  healthy  and  Hvely. 
For  some  months  his  enjoyment  of  life  has  been  less  intense, 
but  he  has  had  no  real  mental  pain.  For  a  few  weeks  he  has 
had  a  strong  impulse  to  take  away  his  life,  and  the  sight  of  a 
knife  at  once  suggests  this  to  his  mind  at  any  time.  He  de- 
plores the  feeUng,  and  it  annoys  liim,  and  he  thinks  himself 
"a  fool"  for  harbouring  "such  nonsense"  in  his  mind,  but  he 
cannot  help  it.  He  has  no  delusions  whatever  about  being 
wicked,  &c.  The  only  other  tiling  wrong  with  liim  is  that  he 
cannot  sleep  very  well.  Change  of  air  and  scene,  after  about 
two  years,  seemed  completely  to  drive  away  the  suicidal  feel- 
ing, but  his  mental  condition  after  was  somewhat  senile,  his 
ambitious  desires  and  enjoyments  being  toned  down,  and  all 
the  keen  edge  of  his  hfe  taken  oflf.  The  suicidal  impulses 
seemed  to  be  a  pait  of  a  climacteric  mental  failure  in  liim. 


.     .  ,  STATES   OF   DEFECTIVE   INHIBITION.  357 

When  the  uncontrollable  impulse  is  towards  self-destruc- 
tion, even  the  lawyers  do  not  deny  its  existence  nor  try  to 
reason  facts  away.  And  they  cannot  attribute  any  sufficient 
"  motive  "  for  such  persons  as  E.  W.  and  E.  X.  putting  an  end 
to  themselves,  though  this  notion  of  a  "motive"  for  suicide 
seems  ineradicable  in  the  public  mind.  Who  ever  saw  an 
account  of  a  suicide  in  a  newspaper  without  an  explanatory 
remark  that  "the  motive  for  the  rash  act  has  not  been  as- 
certained"? It  is  impossible  to  tell  how  many  of  the  1600 
annual  suicides  of  England  are  the  result  of  mere  impulse, 
apart  from  mental  depression,  delusion,  or  alcoholism.  It  is 
common  to  find  the  suicidal  and  homicidal  impulses  combined, 
as  in  the  case  of  E.  V.  (p.  349)  to  which  I  have  referred. 

Destructive  Impulse. — In  childhood  there  exists,  from  pure 
accumulation  of  nervous  and  motor  energy,  that  must  be  let  off 
somehow,  a  desire  to  play,  to  romp,  to  move,  and  to  destroy. 
Most  people  experience  a  morbid  muscular  activity  when  they 
have  "the  fidgets,"  and  few  people  but  have  the  feeling  some- 
times that  they  would  like  to  break  glass  or  smash  something. 
In  many  forms  of  mania  and  in  excited  melancholia  we  have 
destructive  tendencies  as  one  symptom  of  the  general  psy- 
chosis. In  liigh  emotional  tension  women  often  feel  as  if 
they  must  cry  or  break  something,  and  many  women  in 
prison  take  regular  periods  of  "breaking  out,"  during  which 
they  tear  and  destroy  clothes  and  property  without  regard  to 
punishment  or  to  consequences.  In  the  first  stage  of  general 
paralysis  the  morbid  motor  activity  usually  takes  the  form 
of  tearing,  and  it  is  common  for  such  cases  to  have  all  their 
blankets  torn  to  shreds  every  night,  and  to  tear  their  clothes 
during  the  day.  But  the  same  uncontrollable  desire  to  tear 
or  break  may  exist  alone,  without  much  outward  exaltation 
or  depression. 

/  slioio  you  noio  a  young  man  of  25,  E.  Y.,  whose  mother 
was  insane  and  his  brother  paraplegic,  who  for  tioo  years 
required  the  constant  vigilance  of  an  attendant  to  prevent  him 
breaking  lolndows  and  tearing  his  clothes.     He  actually  broke 


358  STATES   OF   DEFECTIVE   INHIBITION, 

over  100  small  panes  of  glass,  and  tore  150  pairs  of  trousers. 
The  reason  he  assigned  for  tliis  was  tliat  he  could  not  help  it, 
and  that  It  was  "  my  conscience  checking  me  "  that  did  it. 
He  was  quite  sprightly  and  joUy,  would  work  in  the  garden, 
would  dance  at  the  ball  as  Hvely  as  any  one,  and  was  never 
suicidal  nor  homicidal,  yet,  when  he  saw  a  window  near,  he 
would  eye  it  as  if  fascinated,  and  if  he  had  a  chance  would 
spring  at  it  and  smash  it,  or  throAV  something  at  it.  He  said 
it  gave  him  great  relief  when  this  was  done.  He  seemed  to 
grow  out  of  this  tendency  as  he  became  more  demented, 
which  he  did  gradually.  The  habit  of  masturbation  increased 
the  tendency  in  him,  and  hard  work  in  the  garden  ordinarily 
diminished  it.  The  bromide  of  potassium  and  cannabis  indica 
kept  it  in  check. 

/  shoio  you  another  patient,  F.  A.,  of  22,  wlio  suddenly  lolien 
at  sea  took  ^^  smashing  fits ,"  the  description  of  which  hy  Dr 
Logie,  his  family  medical  man,  ivas  as  follows : — "  His  bodily 
health  is  good,  but  he  is  subject  to  sudden  fits  of  something 
like  insane  impulse,  continuing  sometimes  for  a  few  minutes 
only,  and  at  others  for  a  whole  day.  During  their  con- 
tinuance he  has  no  control  over  his  actions.  He  says  he 
knows  he  is  doing  something  which  he  ought  not  to  do,  but 
he  cannot  help  it.  At  one  time  the  presence  of  the  fit  is 
manifested  by  his  roaring  aloud  and  using  very  bad  language ; 
at  another  he  will  suddenly  jump  up,  seize  a  chair,  dash  it 
with  violence  on  the  table,  smashing  to  atoms  dishes,  cups, 
and  saucers,  or  whatever  else  may  happen  to  be  on  the  table. 
"When  in  these  states  he  is  exceedingly  violent.  When  inter- 
fered with  on  one  occasion  he  knocked  his  mother  down,  and 
on  another  threatened  to  shoot  his  father,  who  was  trying  to 
control  him.  Unless  when  the  fits  are  on  him  he  is  perfectly 
quiet  and  reasonable.  He  beheves  that  the  fits  are  occasioned 
by  a  person  who  has  power  over  him,  and  can  make  him  do 
as  she  hkes,  and  that  she  first  obtained  that  power  by  putting 
something  in  his  tea."  After  admission  he  would  be  rational 
and  self-controlled  before  these  attacks,  and  again  after.     For 


STATES   OF   DEFECTIVE   INHIBITION.  359 

months  he  had  the  tendency,  though  it  was  less  intense  and 
less  frequent.  As  the  period  of  adolescence  was  passing  into 
manhood  and  his  beard  was  growing  I  expected  him  to  recover. 
I  watched  him  one  night  at  a  dance.  He  looked  absent- 
minded  and  aimlessly  restless.  I  spoke  to  him,  and  he 
answered  me  rationally.  He  looked  pale,  and  his  eyes  were 
glistening.  He  stepped  towards  a  window,  and  suddenly 
smashed  it  with  his  hand,  causing  a  wound.  At  once  he 
seemed  to  get  calm  and  quiet,  and  felt  reheved.  After  a  year 
or  two  he  recovered. 

A  Glass  Smasher. — We  had  on  two  occasions,  as  a  patient 
in  Morningside,  a  man  named  James  Morrison,  who  at 
intervals  of  several  years  had  left  his  home  in  a  Fife  village, 
where  he  worked  as  a  weaver,  and  had  gone  to  Glasgow  once, 
breaking  some  windows  in  the  Cathedral,  and  to  Edinburgh 
twice,  breaking  some  large  plate-glass  windows  in  shops, 
always  quite  coolly,  by  throwing  stones  at  them.  After 
coming  to  the  Asylum  we  could  scarcely  ever  detect  any 
symptoms  of  mental  disease.  He  seemed  to  have  expended 
all  his  morbid  energy  in  the  one  act  each  time.  He  was  a 
man  of  neurotic  heredity  and  good  character,  who  had  no 
motive  for  getting  into  gaol.  He  always  said  he  could  not 
help  smashing  windows ;  that  the  desire  to  do  so  used  to  come 
on  him  in  his  home  in  the  Fife  village,  along  with  a  restless 
unsettled  feeling;  that  he  did  not  break  the  windows  in  the 
houses  of  his  village  because  they  were  too  small  and  "not 
worth  breaking."  It  evidently  would  have  given  no  satisfac- 
tion to  his  morbid  desire  to  break  them.  I  presume  his  was 
just  a  strong  and  uncontrollable  form  of  the  feeling  which 
many  men  have  when  standing  before  a  big  plate-glass 
window  with  a  cricket-ball  in  their  hands. 

Dipsomania. — This  is  a  misnomer  ;  we  do  not  mean  an 
insane  craving  to  drink.  What  is  meant  is  a  morbid  uncon- 
trollable craving  for  alcohol  and  other  stimulants.  What  we 
really  want  is  a  good  word  to  express  the  craving  for  all  sorts 
of  neurine  stimulants  and  sedatives,  as  well  as  alcohol.     The 


360  STATES   OF   DEFECTIVE   INHIBITION. 

confirmed  opium  eater,  the  inveterate  liascliiscli  cliewer,  ttie 
abandoned  tobacco  smoker  are  all  in  the  same  category,  'No 
medical  man  who  has  been  long  in  practice  can  doubt  for  a 
moment  that  there  are  persons  whose  cravings  for  these  things 
are  uncontrollable,  and  who  have  therefore  a  disease  allied  to 
all  the  other  psychokinesiae.  Particularly  the  morbid  craving 
for  alcohol  is  common,  and  so  intense  that  men  who  labour 
under  it  will  gratify  it  without  regard  to  their  health,  their 
wealth,  their  honour,  their  wives,  their  children,  or  their 
soul's  salvation. 

Causation. — Certain  causes  predispose  to  it.  These  are  (1) 
heredity  to  drunkenness,  to  insanity,  or  to  the  neuroses ;  (2) 
excessive  use  of  alcohol,  particularly  in  claildhood  and  youth ; 
(3)  a  highly  nervous  diathesis  and  disposition  combined  with 
weak  nutritive  energy ;  (4)  sHght  mental  weakness  con- 
genitally,  not  amounting  to  congenital  imbecility,  and  chiefly 
affecting  the  vohtional  and  resistive  faculties  ;  (5)  injuries  to 
the  head,  gross  diseases  of  the  brain,  and  sunstroke ;  (6) 
great  bodily  weakness  and  anaemia  of  any  kind,  particularly 
during  convalescence  from  exhausting  disease ;  (7)  the  nervous 
excitement  and  disturbances  of  menstruation,  parturition, 
lactation,  and  the  climacteric  perio(i|  (8)  particularly  exciting 
or  exhausting  employments,  bad  hygienic  conditions,  bad 
air,  working  in  unventilated  shops,  mines,  &c.  ;  (9)  the  want 
of  those  normal  and  physiological  brain  stimuli  that  are 
demanded  by  almost  all  brains,  such  as  amusements,  social 
intercourse,  and  family  hfe ;  (10)  a  want  of  educational 
development  of  the  faculty  and  power  of  self-control  in  child- 
hood and  youth;  (11)  the  occasion  of  the  recurrences  in 
alternating  insanity,  or  the  beginning  of  ordinary  insanity, 
the  morbid  craving  being  coincident  in  a  few  of  these  cases 
with  the  periods  of  depression,  but  mostly  with  the  beginning 
of  the  periods  of  exaltation ;  (12)  the  brain  weakness  resulting 
from  senile  degeneration.  More  than  one  of  these  causes 
may,  and  often  do,  exist  in  the  same  case. 

Sa7ie  or  Insane  1 — The  neurine-stimulant  craving  is  com- 


STATES   OF   DEFECTIVE   INHIBITION,  361 

monly  associated  witli  impulses  or  weaknesses  of  control  in  other 
directions  in  the  majority  of  the  cases,  but  there  may  be  no 
insane  delusion.  Yet  all  the  faculties  and  powers  that  we  call 
moral  are  gone,  at  all  events  for  the  time  that  the  craving  is  on. 
In  typical  cases  the  patients  lie ;  they  have  no  sense  of  self- 
respect  nor  honour ;  they  are  mean  and  fawning ;  they  cannot 
resist  temptation  in  any  form ;  they  are  often  morbidly  erotic, 
especially  at  the  beginning  of  an  attack ;  they  will  steal ;  the 
affection  for  those  formerly  dearest  is  suspended ;  they  have 
no  resolution  and  no  rudiments  of  conscience  in  any  direction. 
The  common  objection  to  reckoning  such  persons  among  the 
insane  is  that,  though  they  have  brains  predisposed  by  heredity, 
they  have  often  brought  this  condition  on  themselves  by  not 
exercising  self-control  at  the  period  when  they  had  the  power 
to  do  so  ;  but  this  applies  to  many  cases  of  ordinary  insanity. 
Another  reason  is  that,  when  deprived  of  their  stimuli  for  a  short 
time,  they  are  sane  enough  in  everything  except  resolution  not 
to  take  to  them  again.  The  excessive  use  for  a  long  period  of 
nerve  stimuli  of  all  kinds  tends  to  diminish  the  controllino- 
power  of  the  brain  in  all  directions,  and  to  lower  its  highest 
qualities  and  finest  points.  The  brain  tissue  is  so  complicated 
and  delicate,  and  its  functions  are  so  inconceivably  varied  and  so 
high,  its  anabolic  and  katabolic  processes  are  so  subtle,  and  the 
slightest  disturbance  may  mean  so  much,  that  under  the  most 
favourable  circumstances  it  runs  many  risks  of  disturbances 
of  its  higher  functions.  But  when  we  have  a  bad  heredity,  a 
bad  education,  and  a  continuous  poisoning  with  any  substance 
that  has  a  special  affinity  for  its  texture,  disturbs  its  circula- 
tion, and  paralyses  its  blood-vessels,  that  excites  morbidly  its 
cells,  that  proliferates  its  neuroglia,  thickens  its  delicate  mem- 
branes, and  poisons  its  embedding  lymphatic  and  cerebro- 
spinal fluids,  we  cannot  wonder  that  its  functions  then  become 
impaired,  and  are  not  fully  nor  readily  resumed  in  all  things. 
The  unfortunate  peculiarity  is  that,  while  we  may  restore  the 
bodily  and  even  the  nervous  tone  so  far  as  vascularity,  sleep, 
and   sensory  functions  are  concerned,  we  have   the   utmost 


362  STATES   OF   DEFECTIVE   INHIBITION. 

diflfictilty  in  restoring  tlie  higher  functions  of  self-control  and 
morahty  in  some  cases.  A  dipsomaniac  when  at  his  worst  is 
readily  recognised  to  be  so  really  insane  as  to  be  in  a  fit  state 
to  be  placed  under  the  control  of  others  for  proper  care. 
When  he  is  at  his  best — after  a  few  weeks  compulsory 
deprivation  of  his  brain  poison — he  is  so  hke  the  rest  of  the 
world  in  all  essential  tilings  that  it  is  very  difficult  to  get 
lawyers  or  politicians  to  frame  laws  to  deprive  him  of  his 
liberty.  "We  cannot  regard  the  drink  craving  alone.  We 
must  be  prepared  to  deal  with  the  opium  eater,  chloral  taker, 
cocaine  injector,  and  ether  drinker.  The  state  of  brain  in  all 
these  is  the  same  in  its  essential  nature.  It  would  be  incon- 
sistent to  provide  against  and  try  to  cure  the  one  without 
including  the  others.  The  Legislature  must  face  the  question 
and  provide  some  remedy  for  this  great  evil  to  society, 
and  the  intolerable  hardsMp  to  the  relatives  of  such  persons. 
The  law  may  not  be  able  at  first  to  cover  the  whole  ground, 
but  it  can  do  something.  Already  several  commissions  have 
reported  strongly  in  favour  of  compulsory  powers  to  treat  such 
persons,  and  the  whole  medical  profession,  who  see  most  of  the 
terrible  results  they  inflict  on  society,  on  their  relations  and 
themselves,  are  unanimous  on  this  question.  We  are  helpless 
tni  we  get  such  an  Act  passed  by  ParHament. 

/  shall  noio  show  you  a  typical  dipsomaniaG,  F.  B.  His 
mother  had  been  melanchohc  at  one  time,  and  her  family  was 
a  neurotic  and  insane  one.  He  was  of  a  nervous  temperament 
from  the  beginning ;  a  flesh  eater  from  a  child  ;  precocious  and 
quiet,  but  not  dogged  in  apphcation ;  vain  to  an  almost  morbid 
extent,  and  in  some  points  not  endowed  with  common  sense. 
At  puberty  he  had  a  slight  attack  of  chorea.  About  17  he 
showed  keen  social  instincts,  but  no  reahsation  of  the  serious- 
ness of  life.  Especially  the  nisus  gen&rativus  was  periodically 
so  strong  as  to  be  difficult  of  control,  and  he  did  not  control  it. 
Becoming  a  "jolly  fellow,"  and  mixing  with  such,  he  took  alco- 
holic stimulants  of  all  kinds  very  freely,  and  showed  a  very 
great  fondness  for  them.     He  occasionally  got  drunk.     About 


STATES   OF   DEFECTIVE   INHIBITION.  363 

20  lie  was  addicted  to  bouts  of  drinking  and  whoring,  which 
came  on  periodically,  and  seemed  to  pass  off  and  leave  him  fit- 
for  his  work.  He  was  ashamed  of  them  afterwards,  and  I 
beheve  at  this  period,  by  his  volition  and  self-control,  he 
sometimes  checked  his  indulgence  in  them  even  when  the 
crave  was  on  him.  At  22  he  was  very  distinctly  worse.  He 
had  less  power  of  applying  himself  to  anything.  He  took 
almost  regularly  recurring  bouts  of  drinking,  during  which 
the  craving  for  alcohol  was  intense  and  quite  irresistible. 
I  have  known  him  drink  turpentine,  eau-de-Cologne,  and 
chloroform  when  he  could  not  get  alcohol.  He  was  nervous, 
tremulous,  and  unable  for  any  kind  of  work  while  the  fit 
lasted.  He  would  lie,  cheat,  steal,  and  associate  with  the 
lowest  characters  at  those  times.  When  he  recovered  he  was 
facile,  lacking  in  conscientiousness,  and  somewhat  unveracious, 
though  a  charming  companion.  All  sort  of  tilings  were  tried 
— long  sea  voyages,  a  colony,  isolation  in  a  doctor's  family, — 
but  no  permanent  improvement  was  produced.  He  sank 
lower  and  lower  mentally  and  morally,  till  at  30  he  was 
really  weak-minded  and  unfit  for  respectable  people  to  associ- 
ate with,  and  unable  to  do  any  work  of  any  kind,  Not  an 
atom  of  self-respect  was  left  in  him.  He  is  now,  at  40,  in  a 
mild  state  of  dementia. 

The  above  is  the  developmental  type  of  dipsomania.  I  have 
only  known  a  few  such  who  recovered.  Treatment  is  usually 
begun  too  late.  In  reality,  persons  with  such  a  constitution 
of  brain  should  live  on  milk  and  farinaceous  food  in  child- 
hood, should  not  be  brought  up  in  cities,  should  never  touch 
alcohol,  should  be  trained  in  strictest  morality  and  with 
little  temptation,  and  should  not  lead  exciting  hard  lives. 
After  they  have  become  dipsomaniacs  they  are  a  curse  to 
all  who  have  to  do  with  them,  a  nuisance  and  a  danger 
to  society,  and  propagators  of  a  bad  breed.  The  essential 
texture  and  working  of  such  brains  are  bad,  just  as  much, 
but  in  a  different  way,  as  an  ordinary  insane  man's.  Such 
cases  may  be  called  dipsomaniacs  by  natural  development. 


364  STATES   OF   DEFECTIVE   IXHIBITION. 

There  is  an  essential  weakness  of  mind  underlying  that 
sort  of  case.  It  is  an  example  of  a  neurosis  of  development, 
ranking  with  chorea,  consumption,  and  adolescent  insanity. 

Here  is  another  kind  of  case  that  might  he  called  reflex. 
F.  C,  a  married  woman,  the  mother  of  a  large  family. 
She  Avas  quite  well,  and  showed  no  drink-craving  till  she 
was  30.  "Wlien  pregnant  with  her  sixth  child — the  three 
previous  children  having  heen  all  born  and  suckled  within 
five  years,  all  her  labours  being  hard,  and  in  one  case  with 
post-partum  haemorrhage — she  became  suddenly  changed 
mentally  and  morally.  She  got  careless,  slovenly,  lazy, 
self-indulgent,  neglectful  of  her  children  and  family  duties, 
evidently  not  so  fond  of  her  husband  and  cliildren,  irritable, 
and  untruthful  In  addition  to  all  this  she  took  to  smoking 
and  drinking.  This  continued  tiU  three  months  after  the 
birth  of  her  cliild,  when  she  became  shghtly  depressed  for 
two  or  three  months,  and  was  then  quite  well  till  next 
pregnancy.  The  same  condition  that  I  have  described  came 
on  again.  It  has  come  on  and  gone  oflf  with  a  certain 
regularity  fifteen  years  now.  I  expect  it  to  cease  at  the 
chmacteric  period.  She  has  had,  by  the  way,  two  attacks 
of  convulsions.  This  form  of  dipsomania  I  look  on  as  an 
undoubted  insanity  and  one  allied  to  alternating  hisanity. 

Here  is  a  common  kind  of  case  through  excess.  F.  D., 
an  educated  professional  man,  whose  heredity  I  could  not 
ascertain,  who  had  worked  very  hard,  and  had  been  very 
successful ;  a  man  of  power,  of  a  nervous  enthusiastic 
temperament,  and  of  great  natural  endurance  and  capacity 
for  work.  He  had  taken  too  httle  hoUday,  and  unfortu- 
nately, from  a  mistaken  idea  of  its  real  use,  had  committed 
the  common  but  terrible  mistake  of  trusting  to  alcohol  to 
restore  his  weariness,  keep  himself  up  to  his  work,  and 
produce  sleep.  It  seemed  to  do  this  at  first.  But  he  soon 
could  not  work  nor  sleep  without  it,  and  it  lost  its  power, 
so  that  he  had  to  take  more  of  it,  and  oftener.  At  last 
he  got  absolutely  dependent  on  it,  bat  it  would  not  make 


STATES   OF  DEFECTIVE   INHIBITION.  365 

him  work  enough.  He  took  still  bigger  doses,  and  had 
an  attack  of  acute  alcoholism.  After  this  he  pulled  up, 
but  only  for  a  time,  and  he  took  to  it  again  with  the  firmest 
resolve  to  restrict  himself  to  small  doses.  In  six  months 
he  was  as .  bad  as  ever,  and  had  several  severe  alcoholic 
convulsions.  This  occurred  again  and  again,  and  he  became 
temporarily  maniacal,  with  all  the  motor  symptoms  of 
alcoholism.  He  got  better  of  this,  took  to  drink  again, 
and  had  convulsions,  mania,  and  alcoholism.  Morally  he 
became  weak,  untruthful,  and  unreliable,  but  never  so  bad 
as  the  youthfully  developed  dipsomaniac  F.  B.  He  died, 
after  a  few  years,  demented,  with  partial  paralysis  and 
diseased  neurogha,  membranes,  and  arteries,  and  with  the 
degenerated  brain  neurine  that  usually  follows  the  continuous 
excessive  use  of  alcohol. 

The  above  seemed  to  he  a  case  of  dipsomania  caused  simply 
by  the  excessive  use  of  alcohol  in  an  originally  good  sound  brain. 
There  is  much  hope  in  such  cases  if  taken  in  time,  if  they 
can  then  be  made  to  see  the  importance  of  absolutely  abstain- 
ing from  alcohol  altogether.  The  continuous  use  of  the 
bromide  of  potassium  I  have  found  useful  in  many  such 
cases.  It  diminishes  the  intensity  of  the  craving,  and  lessens 
the  excitability  of  the  brain.  Never  in  this  nor  any  other 
class  of  insane  drunkards  think  of  tapering  off  the  drink. 
Knock  it  off  at  once,  and  completely.  I  never  saw  any 
dangerous  result  from  this,  but  of  course  the  patients  suffer 
horribly. 

The  moral  treatment  and  management  of  dipsomaniacs  is 
now,  in  the  present  state  of  the  law  that  does  not  allow  legal 
interference  with  their  liberty,  one  of  the  most  unsatisfactory 
things  a  medical  man  has  to'  undertake.  The  relations  and 
friends  of  patients  will  implore  you  to  do  something  or  recom- 
mend something,  yet  nothing  can  in  most  cases  be  done. 
Lunatic  asylums  are  certainly  not  the  proper  places  for  them, 
and  when  sent  there  they  cannot  be  kept  long  enough  to  do 
them  much  good.     What  we  want  is  an  island  where  whisky 


366  STATES   OF  DEFECTIVE   INHIBITION. 

is  unknown;  guardianship  combining  authority,  firmness, 
attractiveness,  and  a  high  bracing  moral  tone ;  work  in  the 
open  air ;  a  simple  natural  life ;  a  return  to  mother  earth  and 
to  nature ;  a  diet  of  fruits,  vegetables,  bread,  milk,  eggs,  and 
fish ;  no  opportunity  for  one  case  to  corrupt  another ;  and 
suitable  punishments  and  deprivations  for  offences  against  the 
rules  of  life  laid  down— r,all  this  continued  for  several  years 
in  each  case,  and  the  legal  power  to  send  patients  to  this 
Utopia  for  as  long  as  medical  authority  determines,  with  or 
without  their  consent.  That  would  be  the  ideal  mode  of 
treatment.  In  real  Hfe  the  best  thing  we  can  do  is  to  send 
our  cases  to  distant  farms  or  manses,  or  doctors'  houses  in 
remote  parts  of  the  Highlands  and  Islands,  under  a  firm 
moral  guardian.  I  am  very  sceptical  about  institutions  for 
dipsomaniacs  where  many  of  them  are  together.  In  that 
case  the  moral  atmosphere  tends  to  be  low,  the  patients  keep 
each  other  in  countenance,  you  cannot  restore  the  sense  of 
shame  and  of  self-respect,  and  they  plot  and  fan  each  other's 
discontent.  If  an  ordinary  dipsomaniac  does  not  want  to  he 
cured,  no  poioer  on  earth  will  cure  Mm.  In  that  case,  no  law 
permitting  forcible  seclusion  wiU  do  any  permanent  good  in 
the  way  of  cure.  It  is  easy  in  many  cases  to  produce  a 
temporary  amendment,  to  rouse  a  sense  of  shame  and  regret 
for  the  time  being,  but  what  is  the  use  of  that  when  they 
return  to  the  world,  if  there  is  no  power  of  inhibition  against 
the  first  glass,  and  when  the  first  glass  creates  an  irresistible 
craving  for  the  second? 

"We  must  take  care  not  to  call  a  case  of  mild  mania,  or  one 
of  melancholia,  or  a  case  of  epilepsy,  or  paranoia,  one  of  dipso- 
mania because  there  happens  to  be  a  craving  for  drink.  In 
such  cases  this  craving  is  merely  one  symptom  of  a  general 
brain  disturbance. 

Kleptomania. — This  interesting  variety  of  uncontrollable 
impulse  seldom,  exists  alone  without  other  morbid  mental 
symptoms  being  present.  The  mere  uncontrollable  desire  to 
appropriate  for  one's-self  what  does  not  belong  to  one  is  an 


STATES   OF  DEFECTIVE   INHIBITION.  367 

instinct  strongly  developed  in  the  animal  kingdom,  in  primi- 
tive and  savage  men,  in  children,  and  in  many  kinds  of  mental 
disease.  Imbeciles  appropriate  and  hide  what  they  fancy, 
just  as  jackdaws  do.  The  desire  is  there,  and  there  is  no 
inhibition.  In  general  paralysis  appropriation  of  all  kinds  of 
things  is  very  common.  I  have  now  a  patient  who  every  day 
stuflfs  his  pockets  with  rags,  stones,  bits  of  glass,  broken 
pottery,  &c.,  till  he  looks  as  if  he  had  a  meal  bag  on  each 
side  of  him.  Every  night  his  attendant  throws  these  things 
away,  but  the  process  is  repeated  to-morrow.  I  once  found 
a  general  paralytic  trying  to  stuff  the  coal-scuttle  into  the 
backside  of  his  trousers.  Some  demented  patients  steal  every- 
thing they  can  lay  their  hands  on.  I  have  very  rarely 
met  with  a  pure  case  of  kleptomania  without  other  mental 
symptoms. 

Pyromania. — A  good  deal  has  been  written  on  the  morbid 
tendency  to  set  things  on  fire.  There  is  no  doubt  that  it 
exists,  but  there  is  more  doubt  about  its  existing  alone  with- 
out other  symptoms  of  insanity.  I  now  show  you  a  marked 
example  of  the  disease,  combined  with  some  melancholic 
depression  of  mind  and  with  one  or  two  delusions, 

F.  E.,  set.  59  on  admission.  The  cause  of  her  attack  was 
mental  distress  at  a  sister's  becoming  insane  and  dying 
in  the  Asylum.  She  was  melancholic  and  suicidal  on 
admission,  and  had  delusions  that  she  had  been  guilty  of 
great  crimes.  At  first  she  tried  to  commit  suicide  by  tying 
pieces  of  cloth  round  her  neck  with  which  to  choke  herself. 
In  six  months  her  mental  condition  assumed  the  form  of  an 
intense  desire  to  set  things  on  fire, — to  set  her  clothes  on  fire, 
to  burn  the  house.  She  became  impulsively  violent  at  times. 
She  set  fire  to  her  hair  one  day ;  another  day  rushed  into  the 
dormitory,  shut  the  attendant  out,  shovelled  the  live  coals 
from  the  fire  on  to  a  mattress,  threw  herself  among  the 
burning  mass,  and  pulled  another  mattress  on  the  top  of  her, 
severely  burning  herself,  and,  in  fact,  nearly  ending  her  life. 
She  sits  saying  to  herself,  "  I  maun  mak  them  low  "  (I  must 


368  STATES    OF   DEFECTIVE   INHIBITION. 

set  them  on  fire)  day  by  day.  In  four  years  tliis  impulse  to 
burn  became  less  intense,  and  sbe  was  more  enfeebled  in 
mind,  and  in  about  six  years  after  admission  sbe  was  thought 
to  have  got  quite  over  it ;  but  one  night  she  went  into  a 
dormitory  and  set  all  the  bedding  on  fire  from  a  gas  jet, 
but  did  not  attempt  to  burn  herself  or  her  clothes.  Now, 
at  the  end  of  nine  years,  she  is  demented,  but  still  has  the 
remains  of  the  old  impulse,  though  in  a  very  shght  degree 
indeed. 

I  was  once  asked  to  see  a  man  called  J.  F.  Wilson,  who 
was  in  the  Edinburgh  Gaol  on  a  charge  of  fire-raising,  having 
at  two  places  set  fire  to  stackyards.  I  found  that  he  had 
once  undergone  punishment  for  a  similar  offence,  and  that  on 
being  taken  up  on  this  occasion,  when  going  with  the  pohce 
sergeant  to  the  station,  he  remarked  on  passing  a  big 
haystack — "That  would  make  a  fine  blaze."  I  found  him  to 
be  a  case  really  of  delusional  insanity  with  a  good  deal  of 
general  enfeeblement  of  mind  and  hallucinations,  hearing 
voices  telhng  liim  to  commit  rape,  and  hearing  the  voices  and 
screams  of  old  friends  often  in  the  night.  In  addition  to  a 
desire  to  set  things  on  fire,  the  sight  of  which  gave  him 
pleasure,  he  heard  the  voice  of  a  female  he  had  once  known 
saying  to  him,  when  he  was  thinking  of  doing  so,  "  If  you 
are  to  do  so,  do  it  quickly."  I  considered  the  causes  of  his 
disease  to  have  been  heredity,  drinking,  and  syphilis.  He 
had  suffered  from  one  attack  of  mania,  for  which  he  had 
been  in  Colney  Hatch  Asylum,  I  did  not  think  he  had  any 
chance  of  complete  recovery.  He  was  found  insane,  and 
sent  to  the  lunatic  department  of  Perth  Prison,  but  was 
discharged  recovered.  Within  a  few  months  he  again  set 
some  stacks  on  fire.  This  time  I  could  discover  no  symptoms 
of  insanity  about  him  but  a  shght  general  mental  enfeeble- 
ment, though  I  had  httle  doubt  he  was  conceahng  and 
denying  insane  delusions,  and  he  received  a  long  sentence  as 
an  ordinary  criminal. 

The  majority  of  the  cases  where  an  uncontrollable  desire  to 


STATES   OF  DEFECTIVE  INHIBITION.  369 

set  things  on  fire  is  the  chief  symptom  of  mental  impulse 
have  been  young  persons  about  the  age  of  puberty  and 
adolescence,  of  strong  nervous  heredity.  In  1895  a  boy  of 
this  kind  nearly  succeeded  in  burning  down  Glenalmond 
School.^  Dr  Campbell  Clark  observes  that  a  considerable 
proportion  of  puerperal  cases  try  to  set  things  on  fire. 

Moral  Insanity. — The  morals  are  lost  or  have  become  altered 
in  many  forms  of  insanity.  The  question,  is — Have  we  any 
examples  where,  from  disease,  a  man.  who  had  up  to  that 
time  been  moral  and  conscientious,  and  obeyed  in  his  conduct 
the  laws  and  the  social  observances,  and  who  had  lost  his  moral 
sense  while  he  retained  his  intelligence  and  reasoning  power, 
having  no  mental  exaltation  or  depression,  and,  in  con- 
sequence of  that  diseased  moral  condition,  spoke  and  acted 
immorally  1  Further  comes  the  question — Did  he,  when  the 
diseased  condition  is  cured  or  recovered  from,  regain  his 
former  morahty  in  feehng  and  conduct  ?  I  have  no  hesitation 
whatever  in  answering  both  questions  affirmatively,  because 
I  have  seen  such  cases.  It  is  not  a  question  of  theory,  but 
of  fact.  A  third  question  arises — Do  we  meet  with  children 
so  constituted  that  they  cannot  be  educated  in  morality  on 
account  of  an  innate  brain  deficiency,  rendering  them  incap- 
able of  knowing  the  difference  between  right  and  wrong,  of 
following  the  one  and  avoiding  the  other,  of  practising  checks 
on  inclination,  of  exercising  self-control  or  obedience  to  the 
laws  of  God  and  man,  of  any  love  and  cultivation  of  the 
good,  or  any  dislike  of  evil  1  Such  moral  idiots  I,  like  others, 
have  met  with  frequently.  Persons  with  this  disease,  and 
persons  with  this  want  of  development,  we  say,  labour  under 
moral  insanity.  It  must  be  understood  that  I  do  not  say 
there  are  many  cases,  if  any,  where  there  is  moral  insanity 
with  absolutely  no  intellectual  or  other  mental  disturbance 
whatever  if  the  patient's  condition  is  subjected  to  a  careful 
analysis.     What  I  say  is  that  there  are  many  cases  where  the 

^  In  most  of  these  cases  there  is  partially  arrested  aud  unrelational 
brain  development. 

2  A 


370  STATES   OF  DEFECTIVE  INHIBITION. 

moral  defects  are  really  tlie  disease,  the  intellectual  defects,  if 
present,  being  so  slight  that  they  would  not  have  constituted 
insanity  nor  have  interfered  with  the  patient's  work  or 
position  in  the  world. 

Conscientiousness,  the  sense  of  right  and  wrong,  is  to  a  large 
extent  an  innate  brain  quahty.  We  see  this  in  children  from 
the  earliest  age.  Some  have  it  strongly,  without  teaching  or 
example ;  others  have  it  sparingly,  and  need  the  most  assidu- 
ous care  to  develop  it.  I  have  referred  to  a  morbid  con- 
scientiousness that  is  sometimes  seen  at  early  ages  in  children, 
and  in  some  of  them  is  followed  by  a  paralysis  of  the  sense  at 
later  periods  of  life.  I  was  once  consulted  about  a  boy  (F.  H.) 
of  ten,  not  an  idiot  nor  an  imbecile,  but  quick  intellectually, 
who  could  not  be  taught  morality.  He  really  seemed  incap- 
able of  knowing  the  difference  between  a  he  and  the  truth,  or, 
at  all  events,  he  never  could  be  got  to  avoid  the  one  and  tell 
the  other.  And  he  hed  without  any  temptation,  and  with  no 
object  to  be  gained.  His  statements  as  to  the  most  ordinary 
matters  of  fact  were  never  beheved,  merely  because  he  made 
them.  He  stole ;  he  had  little  proper  affection  for  his 
brothers  and  sisters  and  parents ;  he  was  incapable  of  the 
sense  of  shame.  When  punished  or  scolded  he  became 
mentally  paralysed  and  in  a  condition  of  stupor,  incapable  of 
knowing  or  doing  anything  whatever.  As  this  boy  approached 
puberty  he  developed  some  moral  sense.  His  grandmother 
had  been  insane.  I  knew  another  boy,  F.  I.,  one  of  a  very 
neurotic  family,  grandmother  insane,  father  a  dipsomaniac, 
and  two  sisters  melancholies,  and  other  two  with  various 
neuroses,  who  was  untrutM ul  and  immoral  instinctively.  No 
one  who  knew  him  ever  believed  a  word  he  said.  He  stole, 
he  had  small  afiPective  power,  and  he  never  seemed  to  see  why 
anybody  should  be  offended  at  acts  of  immorahty  or  dishonour, 
though  he  had  been  carefully  and  rehgiously  brought  up. 
In  after  life  he  turned  out  a  selfish  and  negatively  immoral 
man.  He  never  paid  any  debt  that  he  could  help,  and  he 
borrowed  from  every  one  he  could.     He  treated  his  relations 


STATES   OF   DEFECTIVE  INHIBITION.  371 

badly.  He  on  several  occasions  did  public  acts  that  might 
have  brought  him  under  the  cognisance  of  the  criminal  law. 
■  He  did  these  things  in  a  stupid  way,  as  if  he  himself  was 
quite  unconscious  he  was  doing  wrong.  Such  cases  are  the 
bane  and  disgrace  of  their  friends  and  families,  and  the 
skeletons  in  the  closets  of  their  relations.  ISTothing  can  be 
made  of  most  of  them  morally,  any  more  than  a  genetous  idiot 
can  be  converted  into  an  active-minded  man.  Wrong  is  right 
to  them :  they  prefer  lies  to  truth,  immorality  to  morality. 
I  knew  one  such  case  (F.  K.),  who  was  continually  breaking 
every  commandment  of  the  decalogue.  He  went  through  a 
form  of  marriage  with  four  women,  to  each  of  the  three  last 
having  told  that  he  was  unmarried,  and  I  just  saved  the  fifth 
by  a  few  hours  from  going  through  a  form  of  marriage  with 
him !  Several  members  of  his  family  had  been  insane,  and 
others  subject  to  various  neuroses.  He  took  his  bad  heredity 
out  in  immorality. 

The  occurrence  of  moral  insanity  as  a  disease  in  those  who 
have  previously  had  the  moral  sense,  and  have  exercised  self- 
control,  without  at  the  same  time  the  presence  of  morbid 
mental  exaltation  of  some  sort,  is  not  in  my  experience  so 
common  as  the  want  of  a  moral  sense  from  congenital 
deficiency.  Prichard  quoted  many  such  cases,  and  vividly 
described  the  disease,  but  I  should  place  most  of  his  cases  in 
my  category  of  simple  mania,  like  C.  B.  (p.  147),  C.  C. 
(p.  151),  and  C.  F.  (p.  155).  There  was  in  them  distinct 
morbid  mental  exaltation  along  with  the  loss  of  moral  sense. 
But  in  the  following  extraordinary  case  of  deception,  fraud, 
and  imjposition  there  was  no  ajj'parent  exaltation : — 

F.  L.,  set.  37,  a  lady  of  mixed  race,  her  father  having  been 
English  and  her  mother  of  a  distinguished  Hindustani  family. 
Up  to  the  age  of  thirty  she  had  been  as  other  women,  had 
married,  borne  children,  and  conducted  her  afiairs  discreetly 
under  many  difficulties.  About  that  time  she  entirely 
changed,  morally  and  affectively,  without  intellectual  per- 
version  and  without   mental    elevation  or    depression.     She 


372  STATES   OF   DEFECTIVE   IXHIBITIOX. 

went  to  a  distant  part  of  the  country  wliere  slie  wa=  not 
knoAvn,  got  acquainted  "with  various  persons  there,  especially 
fascinating  one  poor  gentleman  of  a  iDenevolent  disposition. 
She  said  she  was  the  heiress  to  vast  estates  and  to  a  title. 
Through  tliis  gentleman  she  got  introduced  to  other  persons, 
some  of  whom  beheved  her  stories.  She  carried  out  impostures 
most  daringly  and  cleverly.  She  got  introduced,  or  introduced 
herself,  to  one  great  nobleman  after  another.  She  imposed 
on  the  Secretary  of  State  for  India  by  sheer  impudence  and 
lies.  She  went  to  a  pubhc  meeting  where  she  knew  a  noble- 
man of  philanthropic  zeal  was  to  speak,  told  the  doorkeeper 
she  was  an  intimate  friend  of  his,  and  was  shown  into  the 
private  room  reserved  for  him ;  told  him  when  he  arrived 
that  it  was  she  who  was  the  great  support  of  the  movement 
about  which  he  was  to  speak  in  the  district,  was  taken  and 
seated  by  him  on  the  platform,  and  so  got  introduced  to  many 
other  distinguished  persons.  She  raised  large  sums  of  money, 
amounting  altogether  to  many  thousands  of  pounds,  on  no 
security  v/hatever.  She  furnished  many  houses  most  extrava- 
gantly at  the  expense  of  trusting  upholsterers,  and  she  got 
possession  of  jewellery  to  a  large  amount,  largely  on  the  faith 
of  her  distinguished  connection.  To  one  person  she  was  a 
great  Hterary  character — and  she  did  have  printed,  at  other 
people's  expense,  a  volume  of  other  people's  poems  as  her 
own — to  another  she  was  of  royal  descent,  to  another  she  had 
immense  expectations,  to  another  she  was  a  stern  rehgionist. 
All  this  was  the  prelude  to  an  attack  of  hysteria,  brain  soften- 
ing, and  spinal  disease,  of  which  she  died  in  a  year,  demented 
and  paralysed.  And  one  of  the  most  astounding  things  was, 
that  her  first  benevolent  patron  beheved  ia  her  to  the  last, 
came  to  see  her  in  the  Asylum,  and  was  going  to  write  her 
biography  as  that  of  the  most  wonderful  woman  he  had  ever 
come  across— this  being  a  decent  middle-class  man,  who  by  his 
honest  industry  had  made  a  small  fortune,  and  had  lost  £3000 
of  it  through  her.  And  he  was  counted  sane  and  she  insane  ! 
T\"e  meet  with  many  cases  in  both  sexes,  but  especially  in 


THE   INSANE   DIATHESIS.  373 

women,  where  their  "  tempers  "  are  so  had  and  so  uncontrolled 
that  they  do  all  kinds  of  evil  actions  and  cannot  apparently 
help  it.  They  treat  those  nearest  to  them  in  various  wicked 
ways,  making  accusations  against  them  without  foundation, 
and  hurting  their  feelings  and  doing  them  injury  in  the  most 
dehberate  Avay.  I  have  seen  more  than  once  whole  families, 
every  member  of  which  had  a  moral  twist.  I  attended  a 
young  lady  once,  F.  L.  A.,  whose  father  was  cruel,  selfish, 
and  unnatural,  whose  sister  was  an  opium  eater,  sleeping  all 
day  and  sitting  up  all  night,  and  who  was  herself  at  times 
cruel,  lying,  jealous,  hypochondriacal,  and  delighting  in 
annoying  her  friends,  while  at  other  times  she  was  charming, 
amiable,  and  even  fascinating. 

Folie  d,  Deux. — There  is  a  very  curious  condition  of  brain 
in  some  persons  wliich  renders  them  liable  to  become  insane 
by  suggestion  from  others.  They  are  then  said  to  be  affected 
by  "  communicated  "  insanity  or  folie  a  deux.  I  knew  two 
old  maiden  sisters  who  lived  together  a  lonely,  unsocial  life, 
and  who  became  possessed  by  the  same  delusion,  the  one 
"  catching "  it  from  the  other. 

Impsrative  Ideas. — ^This  state  consists  of  morbid  suggestions 
and  ideas  "shot"  across  the  mental  vision,  and  that  seem  to 
dominate  the  mind  and  sometimes  the  will  for  the  time.  A 
man  subject  to  this  condition  may  be  either  sane  or  insane 
according  as  they  affect  his  conduct.  The  case  of  A.  H. 
(p.  43)  is  a  good  example.  His  fear  of  forgetting  words  was 
an  insane  "  imperative  idea." 


THE  INSANE  DIATHESIS. 


Mandsley's  and  Morel's  description  :  Characterised  by  striking  pecu- 
liarities, eccentricities,  oddities,  disproportionate  developments, 
abnormal  affectiveness,  impracticablenoss,  morbid  impulses,  irregular 
action  and  modes  of  life  without  motives  like  other  men — Conuec- 


374  •  THE   INSANE   DIATHESIS. 

tion  with  the  neuroses  and  with  genius — Functional  manifestations 
of  iTnstable  nerve  element  in  its  receptive  and  reaction  aspects — 
Begins  in  childhood — Importance  of  right  upbringing  and  education 
of  body  and  mind. 

A  description  of  tlie  general  symptomatological  forms  of 
mental  disorders  "would  not  he  complete  without  reference  to 
a  condition  of  mentalisation  which  has  been  called  the  insane 
diathesis.  Maudsley,  in  this  country,  and  Morel,  in  Trance, 
have  descrihed  it  better  than  any  other  authors.  The  great 
difficulty  about  its  description  is  that  we  find  few  cases  of 
this  condition  ahke,  and  its  special  manifestations  in  diiferent 
cases  are  as  multiform  as  the  human  faculties  and  as  complex 
as  different  combinations  of  unusual  developments  of  those 
faculties  can  make  it.  There  are  certain  human  beings 
characterised  through  hfe  by  striking  peculiarities,  eccen- 
tricities, originalities  commonly  in  useless  ways,  oddities,  dis- 
proportionate developments,  and  nonconformities  to  rule, 
these  tilings  not  amounting  to  mental  disease  in  any  correct 
sense,  and  yet  being  usually  by  heredity  closely  allied  to  it, 
or  by  evolution  ending  in  it  at  last.  The  children  of  insane 
parents,  or  some  of  the  members  of  families  who  have 
developed  many  of  the  neuroses,  are  most  apt  to  exliibit  the 
symptoms  of  the  insane  diathesis.  Its  symptoms  are  so 
various  that  they  cannot  be  briefly  described.  One  has 
merely  to  read  the  works  of  the  modern  psychological 
novelist  to  find  the  type  of  person  I  refer  to  in  abundance. 
Xo  one  has  lived  long  in  the  world  without  meeting  in  the 
flesh  many  examples  of  it. 

And  there  have  been  enough  examples  of  it  in  the  real 
lives  recorded  in  biographies,  ranging  from  the  inspired 
idiots  to  the  inspired  geniuses  among  mankind.  "We  may 
safely  reckon  Chatterton,  De  Quincey,  Cowper,  Turner, 
Shelley,  Tasso,  Lamb,  and  Goldsmith,  to  take  a  few  men 
of  genius,  as  having  had  in  some  degree  the  insane  tempera- 
ment. "We  find  some  such  persons  strikingly  original,  but 
not  reasonable ;   different  from  other  men  in  their  motives. 


•    .'•  THE  INSANE   DIATHESIS.  375 

in  their  likings,  in  their  ways  of  thinking  and  acting  to  such 
an  extent  that  human  society  would  at  once  come  to  an 
end  were  all  others  like  any  one  of  them.     They  are  all  in 
the  highest  degree   "  impracticable  "  and  "  unwise  "  in  the 
conventional  senses  of  those  words.     Some  are  abnormally 
sensitive  and  receptive,  others  abnormally  reactive.     Some 
are  subject  to   influences   and  motives  to   a  degree   unfelt 
by  ordmary  men,  such  as  hypnotism,  sympathy  with  natural 
forces,  with  animals,  &c.     Most  of  the  spiritualists,  thought- 
readers,  and  clairvoyants  who  are  honest,  as  well  as  many 
"  Bohemians,"  are  of  this  class.     The  actions  of  most  of  them 
may  be  described  as  instinctive.     They  do  not  find  their 
way   to  lunatic   asylums,   but   their   friends  often   have   to 
consult  our  profession  about  them,  especially  in  youth.     And 
fortunate  would  it  be  for  many  of  them  if  the  doctor  had 
the    direction    of    their    upbringing    on    physiological    and 
medico-psychological  principles,  instead  of  the  schoolmaster 
on   doctrinaire   and  purely   mental  ideas.     How   much   un- 
happiness  might   have  been   saved   in  the   world   had   this 
been  done  !     For  if   there  is  any  distinguishing  feature   of 
many  of  them  it  is  the  capacity  to  be  miserable.     Nothing 
reconciles   one   so    to    the   abundance    of    commonplaceness 
and    stupidity   in   the    world    as   a    study    of    the    lives   of 
some  of  these  men.     And  surely  our  profession  will  in  the 
future  be  able,  to  apply  its   knowledge   of  brain   function 
and  development  and  the  laws  of  heredity  towards  making 
the  most  of  such  lives,  strengthening  the  weak  points  without 
forcing  down  the  strong  ones,  saving  from  misery  and  ruin  with- 
out depriving  humanity  of  their  originahty  and  intenseness. 

I  have  one  case  in  the  Asylum  that  may  be  counted  as  of 
the  insane  temperament.  F.  M.,  the  son  of  an  eccentric 
father,  who  could  not  get  on  as  a  student  because  he  would 
insist  on  studying,  not  what  was  prescribed,  but  what  he 
liked,  whose  knowledge  is  prodigious  on  all  subjects — the 
only  man  whom  I  ever  knew  who  had  read  through  the 
Encydo2oeedia  Britannica  and  lived — but  whose  common  sense 


376  THE  INSANE  DIATHESIS. 

is  infinitesimal.  I  never  saw  any  man,  sane  or  insane,  wlio 
could  "  make  such  a  fool  of  himself  "  in  an  ordinary  company 
of  ladies  and  gentlemen.  He  has  most  original  ideas  as  to 
the  future  poHtics  of  Europe,  founded  on  a  profound  study 
of  the  mental  characteristics  and  capacities  of  the  races  who 
inhabit  it.  Yet  he  will  get  up  and  sing  "My  pretty  Jane," 
in  a  large  company,  out  of  tune  and  out  of  time,  and  so 
ridiculously  that  there  is  scarcely  a  dement  in  the  Asylum 
who  will  not  laugh  at  him  and  call  him  "  daft."  He  is 
totally  unfitted  to  "  get  on  "  in  the  world  in  any  way.  I 
presume  it  was  this  that  drove  his  friends,  after  many  trials 
elsewhere,  to  send  him  to  a  lunatic  asylum,  as  the  only  place 
fitted  to  receive  such  a  being. 

Do  not  suppose  for  a  moment  that  all  persons  of  the  insane 
diathesis  are  geniuses  or  talented.     Notliing  could  be  further  . 
from  the  truth.     Most  of  them  are,  on  the  contrary,  very 
poor  creatures  indeed,  a  nuisance  to  their  friends,  and  no 
good  to  the  world  at  large. 

The  insane  diathesis  differs  from  the  German  Erimdre 
VerrucMheit  or  Paranoia  when  this  is  fully  developed.  But 
the  one  state  often  runs  into  the  other.  The  late  King 
Louis  II.  of  Bavaria  was  by  the  highest  German  psychiatric 
authorities  pronounced  to  be  a  typical  paranoiac,  and  his 
career  up  to  the  time  that  he  became  manifestly  insane  was 
that  of  the  insane  diathesis.  Before  he  became  insane, 
his  eccentricities ;  his  impulsiveness ;  his  utter  want  of  the 
sense  of  fitness  and  proportion,  or  even  of  ordinary  morality ; 
his  suspected  unnatural  sexual  practices ;  his  foolish  and 
lavish  expenditure ;  his  appreciation  of  music,  and  his 
romantic  friendship  for  "Wagner;  his  sound  judgment  and 
prompt  action  in  regard  to  Bavaria's  course  in  the  war  of 
1870  all  combined,  make  up  a  vivid  picture  of  a  man  of 
the  insane  diathesis,  who  became  at  last  actually  insane, 
and  a  paranoiac  (see  p.  277). 


LECTUEE  X. 

GEN"EEAL  PARALYSIS  {DEMENTIA  PARALYTICA), 
PARALYTIC   INSANITY. 

A  true  disease,  a  pathological  entity  ;  not  a  mere  group  of  symptoms  ; 
its  importance  and  interest.  Definition :  Three  stages  ;  a  typical 
case.  Etiology  :  Temperament ;  all  causes  of  brain  exhaustion  and 
irritation  ;  excesses  in  drinking  ;  sexual  excesses  ;  over-work  ;  over- 
anxiety  ;  syphilis  ;  injuries  ;  age  at  which  it  occurs  from  25  to  50. 
First  Stage  of  a  Tyincal  Case  :  Elevation  ;  increase  of  sense  of  well- 
being  ;  constant  motion  ;  loss  of  sleep;  exalted  delusions;  "am- 
bitious delirium  ; "  facility  :  fibrillar  tremblings  of  tongue  ;  pa- 
thognomonic speech  ;  slight  inco-ordiuation  of  muscles  of  hands  and 
legs ;  extravagant  conduct ;  acutely  maniacal  state ;  danger  to 
patient's  life ;  difficulty  of  management ;  increase  of  temperature, 
especially  in  evening.  Second  Stage  :  Acute  excitement  passing  off  ; 
gi-eater  facility  and  general  silliness  of  mind  ;  speech,  writing,  and 
walking  affected  ;  dilated  pupils  ;  spurts  of  excitement ;  progression 
of  the  paretic  symptoms  ;  kleptomaniacal  symptoms  ;  surplus  stock 
of  motor  energy  easily  exhausted  by  walking  ;  fragility  of  bones  ; 
epileptiform  fits  ;  "  congestive  attacks."  Third  Stage  :  Paresis 
becomes  paralysis  ;  inability  to  walk  or  speak  ;  occasional  restless- 
ness ;  trophic  lesions  ;  bed-sores  ;  swallowing  impaired  ;  tendency 
to  choke  ;  relaxation  of  sphincters  ;  sensibility  deadened — Duration 
from  18  months  to  3  or  4  years  ;  remarkable  exceptions.  Two 
Pathological  vai-ieties  :  1.  The  cerebral  or  ordinary  ;  2.  The  tabic 
or  the  eccentric  by  pathological  propagation  ;  the  cerebral  by  far 
the  most  numerous.  Symptomatological  varieties  :  1.  Epileptiform; 
2.  Remissional  where  apparent  recovery  takes  place  for  a  time  ;  3. 
Non-delusional  simple  progressive  mental  enfeeblement  ;  4.  Not 
occurring  at  the  usual  ages  ;  5.  The  melahcholic.  Essential  mental 
feature  is  progressive  enfeeblement  and  facility.  What  do  the  grand 
delusions  of  the  general  paralytic  mean  ?  Hereditary  predisposition 
not  so  common  as  in  other  forms  of  insanity.  Chief  Pathological 
Appearances :  Skull-cap  thickened  and  hardened  ;  dura  mater  ad- 
herent ;  general  congestion  ;  thickening  of  pia  mater  ;  adhesion  of 


378  GENERAL   PAEALfSIS. 

pia  mater  to  convolutions  ;  atrophy,  general  and  interstitial,  witli 
compensatory  fluid  ;  and  tissues  ;  lining  membranes  of  ventricles  . 
granular  ;  hardening  of  tissue ;  outer  layer  of  grey  substance 
diseased  ;  proliferation  of  nuclei  destruction  of  nerve  cells  ;  pachy- 
meningitis hsemorrhagica.  Microscojnc  Ajppearanees :  Lewis'  re- 
searches ;  vascular  lymphatic  and  neurine  changes.  Spider  cells  : 
Three  stages  ;  Lewis'  explanation  of  the  facts  ;  the  degeneration 
theory  v.  the  inflammatory.  Premonitory  symptoms  :  "  General 
Paralysis  "  well  expresses  the  universality  of  the  aff"ection  of  the 
nervous  centres  in  advanced  cases  ;  brain,  cord,  retina,  sympathetic, 
and  nerves  aS'ected.  It  is  more  especially  than  any  other  the  disease 
of  the  mind  tissue.  Relation  of  Hitzig's  and  Terrier's  discoveries 
as  to  the  motor  functions  of  the  brain  cortex  to  the  theories  of 
general  paralysis.  Diff'erent  groups  of  muscles  afl"ected  in  difl"erent 
cases.  Are  different  brain  "centres"  aS'ected  in  such  cases? 
Diseases  with  which  it  may  in  some  cases,  or  in  some  of  its  stages, 
be  confounded  :  1.  Alcoholism  ;  2.  Syphilis  of  brain  ;  3.  Epilepsy  ; 
4.  Acute  mania  ;  5.  Tumours  of  brain  ;  6.  Brain  atrophy  ;  7. 
Chorea  ;  8.  Partial  aphasia  ;  9.  Ramollissement  ;  10.  Senility. 

General  Paralysis  is  not  only  a  variety  of  insanity  but  a 
true  cerebral  disease,  as  distinct  from  any  otlier  disease  as 
small-pox  is  from  scarlatina.  It  is  a  disease  of  extraordinary 
interest  physiologically,  patliologically,  and  psycliologically. 
Its  study  has  somatised  and  definitised  the  study  of  all  mental 
diseases,  and  has  added,  and  wiU  add  still  more,  to  our  know- 
ledge of  the  connection  of  mind  with  body,  and  of  mental  and 
motor  disturbances.  Wliat  we  knew  of  its  symptoms  and 
pathology  ought  to  have  led  to  the  conclusion  that  the  cerebral 
convolutions  have  motor  functions  long  before  HughKngs 
Jackson,  Hitzig,  and  Ferrier  arrived  at  their  generahsations 
on  the  subject.  Being  a  distinct  disease,  clinically  and 
pathologically,  it  can  be  defined  or  described  definitely,  and  I 
should  give  its  definition  thus  : — An  organic  disease  of  the  corti- 
cal jpaH  of  the  brain,  characterised  hy  progression,  hy  the  com- 
bined presence  of  mental  and  motor  symptoms,  the  former  aliuays 
includiiig  mental  enfeeblement  and  mental  facility,  and  often 
delusions  of  grandeur  and  ideas  of  morbid  expansion  or  self- 
satisfaction  ;  the  motor  deficiencies  always  including  a  peculiar 
defective  articulation  of  loords,  and  always  passing  through  the 


•    ■  •  GENERAL   PARALYSIS.  379 

stages  of  fibrillar  convulsion,  inco-ordination,  jmresis,  and 
paralysis;  the  diseased  process  spreading  to  the  tolwle  of  the 
nerve  tissues  in  the  body  :  being  as  yet  incurable,  and  fatal  in  a 
feiv  years. 

Three  Stages. — The  disease,  for  convenience  sake,  has  been 
divided  into  three  stages.  In  typical  cases  the  first  of  these 
is  that  of  fibrillar  tremblings  and  slight  inco-ordination  of 
the  muscles  of  speech  and  facial  expression,  and  of  mental 
exaltation  with  excitement ;  the  second  that  of  muscular 
inco-ordination  and  paresis,  with  mental  enf  eeblement ;  and 
the  third  that  of  advanced  paresis,  with  little  power  of  pro- 
gression, almost  inarticulate  speech,  and  at  last  paralysis, 
with  mental  extinction.  These  stages  form  a  convenient 
basis  for  the  study  of  the  disease. 

Let  us  looh  at  a  typical  case  in  the  first  stage  of  the  disease. 

F.  Y.,  a  fine,  strong,  handsome  man  of  thirty-five,  without 
any  known  hereditary  predisposition  to  insanity.  He  had 
enjoyed  good  health  up  to  the  time  of  his  present  attack. 
His  temperament  is  sanguine,  diathesis  neuro-arthritic,  and 
his  disposition  frank,  unsuspicious,  boastful,  and  hasty.  He 
always  had  a  high  opinion  of  himself,  and  showed  it ;  was 
of  an  imaginative  turn ;  and  had  a  physiological  tendency  to 
exaggeration.  His  feeling  of  bien  etre  was  always  above  the 
average  ;  his  habits  had  been  industrious,  and  at  times  he  had 
worked  very  hard  indeed.  He  had  not  been  dissipated  in  the 
worst  sense,  but  he  had  lived  freely,  taking  lots  of  alcoholic 
stimulants  habitually,  eating  much,  sleeping  generally  too 
.  little,  and,  above  all,  exceeding  greatly  in  regard  to  sexual 
intercourse,  both  before  his  marriage  and  since — he  had  been 
married  for  three  years.  He  had  never  had  sj^philis  that  I 
could  make  out,  and  certainly  has  no  evidence  of  the  disease 
on  his  body.  For  a  few  months  his  friends  have  noticed  that 
he  "  has  not  been  the  same."  Six  months  ago  he  was  "  not 
in  good  spirits,"  and  complained  of  flying  pains  in  the  head ; 
then  he  was  a  little  forgetful,  wanting  in  appHcation  to  his 
work,  restless,  doing  some  "  unaccountable  things  "  in  business, 


380  GENERAL  PARALYSIS. 

e.g.,  forgetting  to  claim  money  due  to  him.  He  was  irritable 
at  home,  a  thing  unusual  with  him.  A  month  ago  he  began 
to  express  an  exaggerated  sense  of  well-being,  saying  he  never 
was  so  well  in  his  Hfe,  that  his  strength  was  "sometliing 
wonderful."  He  could  not  settle  down  to  liis  daily  work,  his 
natural  high  opinion  of  himself  was  more  openly  expressed  to 
comparative  strangers,  one  of  whom  remarked  after  seeing 
him,  "  Wliat  a  conceited  fool  that  man  is."  This  state  went 
on  without  any  other  absolute  signs  of  insanity,  and  without 
awakening  the  suspicions  of  his  friends  that  he  was  mentally 
wrong — that  is  always  about  the  last  thing  thought  of, — until 
one  morning  he  announced  to  his  wife  that  he  had  the  day 
before  purchased  several  hundred  pounds'  worth  of  silver 
plate,  and  had  ordered  his  coat-of-arms,  with  his  name  in  full, 
to  be  engraved  on  each  article.  He  added  that  he  had  lots  of 
money,  and  had  a  scheme  through  which  in  a  week  he  would 
be  worth  many  hundreds  of  thousands  of  pounds.  On  inquiry 
it  was  found  that  he  had  ordered  the  plate ;  but  the  jeweller, 
being  a  man  of  sense  and  principle,  having  noticed  some  little 
thing  in  his  manner  that  savoured  of  morbidness,  had  not 
taken  any  steps  to  execute  the  order  till  he  made  some 
inquiries.  Many  commencing  general  paralytics  are  not  so 
lucky  as  this.  I  knew  one  who  spent  £1000,  that  had  taken 
Mm  ten  years  to  make,  in  the  week  before  his  disease  was  dis- 
covered, and  another  who  spent  £7000  in  a  month.  F.  Y.'s 
wife  found  that  he  had  been  buying  a  quantity  of  perfectly 
useless  things  in  addition  to  the  plate,  some  of  them  in  duph- 
cate.  He  had  in  his  pocket  four  gold  pencil-cases,  which  he 
said  he  was  to  give  away  as  presents  to  people  to  whom  he 
was  under  no  obligation,  and  did  not  know  very  well.  -She,  of 
course,  saw  that  something  was  wrong,  and  he  Avas  got  off 
to  the  country.  The  restlessness  by  night  and  day  increased  ; 
there  was  constant  talking,  almost  complete  sleeplessness  ;  the 
boastfulness  became  in  three  or  four  days  exaggerated  delu- 
sions. He  said  he  could  lift  1000  lbs.  ;  that  he  was  the  best 
rider,  swimmer,  and  jumper  in  the  world.     He  wanted  to  buy 


.    .-.  GENEKAL   PARALYSIS.  381 

every  farmer's  horse  he  met  on  the  road,  never  offering  less 
than  £100  for  any  animal,  and  at  once  bidding  another  £100 
if  the  first  offer  was  jocularly  refused.  He  wrote  quantities 
of  letters  to  all  his  friends,  to  all  the  noblemen  in  the  district, 
and  to  the  Queen,  offering  his  services  to  make  their  fortunes 
and  asking  them  to  dinner.  The  only  visible  peculiarity  of 
the  writing  was  the  omission  of  many  single  words.  In  a 
few  more  days  he  was  maniacal,  and  so  impatient  of  contra- 
diction that  he  struck  his  wife,  yet  through  all  this  he  was  in 
some  respects  facile  and  easily  managed.  He  therefore  had 
to  be  brought  to  the  Asylum  a  week  ago.  "When  he  saw  me 
he  offered  to  buy  the  institution  for  £100,000,  and,  on  my 
saying  that  was  too  little,  offered  £200,000,  and  soon  got  up 
to  £1,000,000.  On  my  saying  that  we  could  not  do  without 
it,  he  said  he  would  build  another,  the  most  magnificent  in 
the  world,  and  endow  it  with  a  million  a  year,  and  appoint 
me  physician-in-chief  with  a  salary  of  £10,000,  first  getting 
the  Queen  to  create  me  a  baronet  and  giving  me  a  splendid 
uniform,  cliiefly  made  of  gold  cloth.  He  has  been  sleepless, 
•  destructive  to  his  clothing,  not  cleanly  in  his  habits  or  modes 
of  eating,  in  constant  motion,  facile  in  most  respects,  but 
irritable  and  impulsively  violent  when  his  commands  were 
not  instantly  obeyed,  or  when  he  was  prevented  from  carry- 
ing out  his  grand  schemes.  He  expressed  no  surprise  at  being 
brought  here  at  all,  and  no  resentment  towards  those  who 
brought  him. 

Look  at  him  now.  He  came  into  the  room  with  a  quick 
step.  His  attitudes  and  gestures  follow  and  accentuate  his 
speech.  He  talks  rather  quickly,  and  has  the  least  slurring 
towards  the  end  of  long  sentences  and  in  articulating  long  and 
difficult  words  with  many  oft-repeated  consonants.  "  Eound 
about  the  rugged  rock  the  ragged  rascal  ran  "  was  got  through 
fairly  well  the  first  time,  but  at  the  second  attempt  the  "  ragged 
rascal "  got  into  a  sort  of  inarticulate  slur.  This  is  accompanied 
by  fibrillar  twitching  in  the  small  muscles  of  the  lips  and 
round  the  eyes,  as  if  a  sudden  electric  current  had  set  these 


382  GENERAL   PARALYSIS. 

quivering.  As  he  breaks  into  a  smile  tHs  is  very  apt  to 
happen.  His  tongue  quivers  in  lines  on  its  surface,  single 
strands  of  muscles  heing  affected.  His  pupils  are  contracted, 
irregmlar  in  outline,  and  the  right  is  distinctly  larger  than  the 
left,  the  latter  being  quite  insensitive  to  Hght.  Sometimes  it 
is  one  pupil  and  sometimes  the  other  that  is  small  and  insen- 
sitive, or  large  and  insensitive,  in  different  cases.  The 
expression  of  his  eyes  is  feverish  and  strange.  His  skin  is 
moist,  and  feels  hot.  His  temperature  is  99'6°,  this  rising  to 
over  100°  at  night ;  his  pulse  is  full  and  hard.  He  cannot  rest 
nor  sit  still.  There  is  clearly  an  abnormal  generation  of  energy 
in  his  motor  batteries.  When  we  test  his  common  sensation, 
it  is  found  to  be  markedly  diminished.  His  sense  of  smell  is 
weakened,  though  it  is  not,  as  Voisin  says,  so  blunted  that  he 
cannot  smell  pepper,  I  have  seen  only  a  few  cases  where 
smell  was  so  anesthetic  as  this.  He  tastes,  though  a  little 
imperfectly ;  by  and  by  he  wHl  not  be  able  to  distinguish  a 
solution  of  quinine  from  milk.  Shown  a  lot  of  coloured  wools 
he  could  not  tell  the  blue,  calling  it  red.  His  patellar  tendon 
reflex  is  very  acute,  and  also  the  spinal  and  skin  reflexes. 
You  noticed  how  easily  he  was  led  off  from  one  subject  to 
another ;  this  facility  is  one  of  the  most  characteristic  of  all 
the  symptoms  present  in  all  stages  of  the  disease.  But  he  is 
irritable  on  contradiction,  and  resents  thwarting,  especially  if 
it  is  done  suddenly  and  imperiously.  General  paralytics  at 
this  stage  are  sometimes  very  dangerous,  from  their  absolute 
fearlessness  of  consequences.  This  insane  boldness  gives 
much  trouble.  An  ordinary  insane  patient,  if  not  deliriously 
maniacal,  will  usually  yield  to  the  show  of  force,  but  a  general 
paralytic  will  often  try  to  fight  and  resist  any  number  of  men. 
When  we  try  him  to  v;alk  along  a  board  of  the  floor  he  does 
so  sprightly  and  well,  but  on  telling  him  suddenly  to  turn 
round  he  could  not  do  so  sharply,  but  took  a  circle,  and  that 
waveringly. 

This   man  is   in  the   first   stage  of   his  disease.     He   will 
steadily  groAV  worse,  losing  bodily  weight  rapidly,  his  speech 


■    •'•   .  GENERAL  PAEALYSIS.  383 

getting  worse,  more  tremulous,  and  having  more  difficulty  in 
articulating  long  words  and  sentences.  His  motor  excitement 
will  be  shown  probably  by  his  tearing  dozens  of  suits  of 
clothes  all  to  ribbons,  I  have  a  gentleman  who  tore  one 
greatcoat  into  over  a  hundred  pieces,  saying — "  I'm  g-g-going  to 
put  it  tog-g-ger  again  as  soon  as  I  g-g-get  to  Jeru-sh-lem.  I've 
got  a  million  coats  there."  His  walking  will  become  affected, 
and  his  mental  power  will  become  gradually  more  enfeebled. 
He  will  believe  all  the  delusions  of  his  fellow-patients.  A 
general  paralytic  is  about  the  only  insane  person,  except  a 
congenital  imbecile,  who  cannot  see  that  some  of  his  fellow- 
patients  in  an  asylum  are  insane.  Their  letters  are  usually 
characteristic.     Here  is  one  : — 

"The  ...  ^  of  the  Millenium.  R.  E.  A.  When  I  reach  the  elect, 
teleght.  office  will  send  a  despatch  the  Times.  Millenum  begins.  Yours 
in  the  Holy  love  of  God  and  the  Holy  Trinity,  Israel  Jesu  Christ." 

Here  is  another,  addressed  "  Countess  of  Elgin  and  Durham," 
but  really  to  the  Queen  : — 

" HoTTSE,  Royal  National  Lunatic  Asylttm. 

"My  Dear  Wife, — I  am  very  glad  to  say  that  I  am  up  to  the  mark 
in  every  particular,  and  hope  your  system  is  up  to  the  scratch.  Has 
John  Brown  undergone  any  form  of  cremation  ?  I  am  glad  to  .  .  .  him 
adopting  my  style  of  shepherd  checked  trousers.  I  hope  both  Queens 
are  well,  with  Princess  Louise,  Princess  Beatrice  .  .  .  that  I  will  give 
them  all  that  is  necessary  in  this  world  and  the  world  to  come.  Compts. 
to  darling  '  Eugene.' — Your  affct.  husband." 

The  nisus  generativus  is  usually  not  exalted  except  in  the 
preliminary  stage  of  general  paralytics,  but  I  have  known 
exceptions  to  this.  In  fact,  impotence  is  the  rule  during  the 
latter  end  of  the  first  stage,  and  ever  after.  I  have,  however, 
known  cases  where  children  were  procreated  in  the  beginning 
of  the  first  stage,  and  I  had  one  case  who  was  impotent  for 
over  a  year  in  the  first  stage,  but  whose  sexual  power  returned 
in  the  second  stage,  with  many  other  apparent  signs  of  improve- 
ment, and  his  wife  had  a  child  to  him,  begotten  then.     He 

^  Where  words  are  omitted. 


384  GENERAL   PARALYSIS. 

again  became  impotent  in  the  end  of  the  second  stage.  I  have 
known  more  than  one  case  of  general  paralysis  who  was  a 
masturbator  during  the  early  part  of  the  first  stage. 

Let  us  now  see  a  typical  case  in  the  second  stage  of  the 
disease. 

F.  X.,  now  45,  a  clerk,  with  a  history  somewhat  resembling 
F.  Y.  He  became  affected  a  year  ago,  and  has  gone  through 
a  first  stage  of  exaltation  and  excitement,  which  for  the  past 
two  months  has  been  slowly  passing  off.  Mark  his  facial 
expression,  or  I  should  rather  say,  his  want  of  facial  expres- 
sion. His  face  looks  fat,  heavy,  and  dull,  as  if  the  expres- 
sion had  been  wiped  out  of  it,  and  this  even  when  he  speaks. 
There  are  no  movements  of  the  features  corresponding  with 
the  emotions  he  is  experiencing.  There  is  a  heavy  fiabbiness 
about  him.  After  losing  over  two  stone  in  the  first  stage  of 
the  disease,  he  has  now  made  it  up  again  in  fat  if  not  in 
muscle.  There  is  a  contented  facile  hebetude  of  mind  in  him. 
He  expresses  few  wants,  says  he  is  quite  well,  and  that  he 
can  walk,  work,  sing,  or  do  business  as  well  as  he  ever  did, 
none  of  which  are  true,  for  he  is  very  shaky  on  his  legs, 
cannot  walk  a  mile,  his  handwriting  is  tremulous,  and  he  has 
no  initiative  mental  power,  no  spontaneity,  and  no  power  of 
volition.  He  does  not  now  obtrude  his  delusions,  but  when 
asked  he  still  says  in  a  facile  way  he  is  rich  and  strong. 
His  pupils  are  widely  dilated,  and  the  left  more  so  than  the 
right ;  his  pulse  is  68,  and  easily  compressible  ;  his  tempera- 
ture 97°,  but  still  a  httle  higher  at  night ;  his  tendon  reflex 
is  dull ;  his  spinal  reflex  functions  dull  too ;  his  power  of 
swaUoAving  a  httle  impaired.  His  speech  is  very  markedly 
affected  now,  and  the  tone  of  his  voice  is  quite  changed.  He 
cannot  say  "round  about  the  rugged  rock  the  ragged  rascal 
ran  "  at  all,  nor  such  test  words  as  "royal  artillery,"  "  hippo- 
potamus," "British  constitution,"  &c.  There  are  still  some 
tremblings  about  his  face  as  he  speaks,  but  they  consist  of 
the  inco-ordination  of  whole  groups  of  facial  and  articulatory 
muscles.     He  is  very  kleptomaniacal,  picking  up  and  stuffing 


■    ■'•  GENERAL  PARALYSIS.  385 

into  his  pockets  any  bit  of  trash  he  can  lay  hands  on.  The 
dorsum  of  his  tongue  presents  a  general  undulatory  surface 
when  put  out.  He  cannot  turn  round  quickly  without 
risk  of  falling,  or  stand  on  one  leg  ;  he  straddles  a  little  in 
walking,  is  apt  to  stumble  over  small  obstacles,  and  the  effort 
of  a  long  walk  so  exhausts  the  energising  power  of  his  motor 
batteries  that  he  gets  almost  paralysed,  and  is  then  unable  to 
walk  at  all.  There  is  no  vigour  in  any  muscular  movement 
he  performs.  His  urine  often  dribbles  away.  Occasionally 
he  is  noisy  at  night  in  an  automatic,  causeless  way.  He  will 
become  weaker  steadily.  His  speech  will  soon  become  less 
articulate,  until  he  reaches  the  third  stage,  loMch  this  next 
patient  has  reached. 

F.  W.,  set.  40.  Has  had  general  paralysis  for  two  years, 
and  has  passed  through  the  first  and  second  stages.  He  is 
now  so  paralysed  that  he  cannot  walk  nor  even  stand  steadily. 
He  cannot  write,  and  his  mental  state  is  that  of  a  happy 
lethargy.  When  asked  if  he  has  a  million  of  money  his 
facial  muscles  begin  to  act  in  an  inco-ordinated  way,  his 
eyelids  half  shutting,  his  mouth  being  drawn  out,  the  lips 
moving  spasmodically  like  a  patient  going  into  an  epileptic  fit, 
the  whole  efi'ect  being  that  of  a  contorted  imitation  of  a  smile, 
accompanied  by  a  slow,,  prolonged,  and  jerky  "  Y-a-a-a  " — which 
is  all  that  he  can  articulate  for  "Yes."  But  he  looks  as  if  his 
subjective  condition  was  one  of  perfect  happiness.  He  asks 
for  nothing,  he  complains  of  nothing;  he  is  noisy  at  night 
often,  but  it  is  in  an  automatic  way.  He  needs  to  sleep  on  a 
mattress  on  the  floor  in  a  room  specially  warmed  by  hot  air, 
for  he  rolls  about  the  room  at  night.  He  is  quite  unable  to 
retain  his  urine  and  fseces  by  night  or  day.  All  his  food  has 
to  be  liquid  or  minced,  for  he  would  bolt  it  in  solid  masses  and 
choke.  He  is  greedy  for  his  food  when  it  is  put  into  his 
mouth,  though  he  is  unable  to  feed  himself.  This  man  had 
two  "congestive  attacks,"  to  which  most  general  paralytics 
are  subject.  One  occurred  about  the  end  of  the  first  stage 
of  the  disease,  and  was  accompanied  by  unconsciousness,  a 

2  B 


386  GENEEAL  PAKALYSIS. 

temperature  of  103°,  general  convulsions  "which,  began  and 
ended  on  the  right  side,  but  affected  the  whole  body  in  the 
middle  of  the  attack.  They  lasted  for  about  four  hours,  and 
were  succeeded  by  stupor,  Avhich  lasted' for  forty-eight  hours. 
He  had  retention  of  urine  at  that  time  as  he  slowly  recovered 
consciousness  ;  after  that  it  was  found  that  his  speech  and 
his  walking  were  more  paretic,  and  his  mental  power  more 
enfeebled.  Congestive  attacks  always  leave  the  patients 
worse  in  these  respects.  The  second  attack  was  of  the 
same  character,  but  less  severe,  and  occurred  in  the  second 
stage, 

Hcematoma  auris. — Soon  after  it  a  fellow-patient  struck 
him  on  the  side  of  the  head,  and  the  ear  of  that  side  began 
to  sweU  in  the  centre  of  the  helix,  this  swelling  slowly 
increasing  in  size  until  the  ear  was  painted  with  blistering 
fluid,  as  recommended  by  Dr  Hearder,  when  it  ceased  to  in- 
crease in  size,  and  slowly  shrank  up,  leaving  that  part  of  the 
ear  hard  and  slightly-  shrivelled.  If  it  had  not  been  bhstered 
the  swelling  would  have  increased  until  the  whole  ear  would 
have  looked  like  a  bluish  egg  attached  to  the  side  of  the  head. 
This  would  have  been  found  to  consist  of  a  bloody,  gelatinous 
material  if  it  had  been  opened — but  this  should  not  be  done — 
apparently  separating  the  outside  skin  of  the  ear  from  the 
cartilage.  In  time  it  would  have  shrunk  up,  leaving  the 
outside  ear  a  hard,  shrivelled,  cartilaginous-looking,  ill-shapen 
mass.  This  is  the  "insane  ear,"  or  hcematoma  auris,  which 
is  very  common  in  general  paralysis,  and  is  sometimes  seen 
in  bad  cases  of  mania  of  the  chronic  variety,  sometimes  in 
chronic  epileptics,  occasionally  in  agitated  and  convulsive 
melancholia,  and  rarely  in  dementia.  Its  occurrence  is  always 
a  bad  sign  for  prognosis  in  any  case  of  insanity.  I  liave  seen 
only  four  or  five  cases  perfectly  recover  out  of  over  eighty 
Avho  had  fully  developed  hcematoma  auris,  and  four  others 
who  made  partial  recoveries  after  slight  threatenings  of  hasma- 
toma  which  might  not  have  developed  fully  or  were  stopped 
by  blistering  fluid.     It  results,  according  to  Drs  Middlemass 


GENEKAL  PAEALYSIS.  387 

and  Eobertson,^  from  "a  peculiar  degeneration  in  the  cartilage 
of  the  ear."  The  real  seat  of  the  hsemorrhage  is  in  the* 
cartilage  branches  of  the  carotid  artery.  The  gelatinous, 
bloody  contents  of  a  hsematonia  are  Hke  the  extravasations 
under  the  dura  mater  in  pachymeningitis  hcemorrliagica 
interna,  a  disease  that  is  liable  to  occur  in  precisely  the  same 
class  of  cases.  Hcematoma  auris  has  been  found  in  persons 
sane  in  mind,  though  very  rarely.  •  The  exciting  cause  is 
often  violence  to  the  ear,  but  this  is  not  necessary,  and 
scarcely  any  violence  will  cause  such  a  state  of  the  ear 
where  the  morbid  conditions  for  its  formation  do  not  exist. 
Blistering,  if  apphed,  in  time,  usually  stops  further  growth, 
but  I  have  met  with  cases  where  a  hsematoma  began  to  grow 
after  it  had  been  thus  stopped,  was  again  blistered,  again 
ceased  to  grow,  then  again  enlarged,  and  finally  swelled  up 
to  the  size  of  an  egg  in  spite  of  blistering. 

F.  W.'s  common  sensibility  is  much  impaired,  so  that  you 
can  stick  pins  into  him  without  his  feeling  it  much.  The 
reflex  action  of  his  cord  is  over-acute,  and  extends  upwards 
from  the  section  of  cord  irritated,  for  if  you  tickle  one  foot 
they  are  both  drawn  up  with  a  jerk,  and  the  two  hands  and 
the  chest  muscles  are  contracted  likewise.  The  impression 
travels  upwards  more  readily  than  downwards. 

He  will  soon  become  so  paralysed  that  voluntary  motion 
of  any  kind  in  the  legs  will  cease.  He  will  have  to  be  placed 
on  a  water  mattress,  and  his  trophic  power  will  become  so 
affected  that  his  urine  will  irritate  his  skin  and  bed-sores  will 
tend  to  form,  and  he  will  die  of  exhaustion  probably  Avithin 
six  months  from  this  time,  or  within  three  years  from  the 
beginning  of  his  disease. 

Variatio7is  from  the  Typical  Form. — The  usual  course  of 
this  disease  is  well  illustrated  by  these  three  patients,'  but  a 
large  number  of  the  cases  do  not  follow  the  typical  course, 
and  it  is  the  non-typical  cases  that  puzzle  us  in  diagnosis, 
about  whom  the  most  experienced  of  us  have  to  suspend  our 
1  EcUn.  Med.  Jour.,  Dee.  1894. 


388  GENERAL   PARALYSIS. 

judgment  in  the  early  stages.  For  the  diagnosis  of  those 
exceptional  cases,  we  require  first  to  know  clinically  the 
varieties  that  are  found,  to  understand  and  to  take  into 
account  the  true  pathological  nature  of  the  disease,  and  to 
be  able  to  separate  the  essential  from  the  non-essential 
features  of  it.  I  shall  instance  a  few  varieties  of  the  disease. 
The  most  marked  variety  is  the  peripheral  form,  where  the 
pathological  process  does  not  begin  in  the  cortex  of  the  train 
hut  in  the  cord  (the  tabic  form),  or  in  the  neurine  portions  of 
the  organs  of  special  sense  {the  sensor  ij  form),  or  in  a  peripheral 
nerve  {the  peripheral  form),  spreading  upwards  by  a  patho- 
logical propagation  along  the  connecting  nerves  in  the  hnes 
of  physiological  function,  till  it  reaches  the  brain  cortex. 
These  varieties  are  rare,  but  distinct  enough  when  they  occur, 
and  very  interesting.  They  would  seem  to  imply  that  the 
pathological  process  of  general  paralysis  resembles  the  pro- 
gressive Wallerian  atrophy  of  the  nerve  trunks,  or  the  de- 
generation of  the  posterior  columns  of  the  cord  in  locomotor 
ataxia.  I  am  not  quite  prepared  to  accept  this  conclusion, 
for  there  are  as  yet  many  pathological  differences  between 
the  appearances  of  both  of  these  and  the  brain  cortex  as 
affected  by  general  paralysis.  The  essential  structure  and 
the  functions  of  the  brain  cortex  are  so  different  from  any 
other  portion  of  the  nervous  system  that  it  is  quite  possible  to 
suppose  a  diseased  process  of  one  pathological  nature  slowly 
advancing  along  a  peripheral  nerve  or  along  the  cord,  and, 
when  it  reaches  the  totally  different  and  higher  structure  of 
the  brain  cortex,  that  it  should  assume  a  different  nature,  just 
as  the  process  of  infiammation  spreading  from  the  periosteum 
to  the  bone  changes  its  character  in  some  respects.  And  then 
it  must  be  remembered  that,  in  those  rare  cases  of  what 
appear  to  be  pathological  propagation,  there  may  have  been 
the  ordinary  causes  of  general  paralysis  operating  in  regard 
to  the  cortex,  and  the  peripheral  disease  may  have  been 
merely  an  extra  cause  at  work.  To  show  what  I  mean  I 
shall  refer  to  a  few  cases. 


■    •  '  GENERAL  PAEALYSIS.  389 

G.  A.,  a  man  of  50,  who  had  been  affected  with  ordinary 
typical  locomotor  ataxia  for  seven  years,  began  to  be  maniacal 
and  sleepless,  and  to  have  delusions  of  grandeur,  affirming 
he  was  an  earl  and  possessed  millions  of  money,  and  that  he 
could  ride,  run,  and  swim  better  than  any  man  in  the  world. 
He  used  to  write  about  fifty  letters  a  day,  ordering  every  sort 
of  thing  imaginable,  asking  the  Queen,  the  House  of  Lords, 
and  the  Cabinet  to  dinner,  &c.  His  speech  was  markedly 
affected  by  the  characteristic  tremble  of  the  lips,  the  shuffle 
and  thickness  in  the  articulation  of  long  words  and  sentences. 
He  passed  through  the  second  and  third  stages  of  the  disease, 
and  died  in  eighteen  months  from  the  time  of  the  beginning 
of  the  mental  symptoms.  There  was  no  post-mortem  examin- 
ation in  that  case,  but  I  have  examined  the  brain  and  cord  in 
other  similar  cases,  and  have  found  that  the  disease  could  be 
traced  up  from  the  cord  through  the  medulla  and  the  lower 
ganglia  into  the  brain  cortex,  I  have  always  found  in  those 
tabic  cases  that  the  pecuhar  adhesion  of  the  pia  mater  to  the 
convolutions  (see  Plate  I.,  Frontispiece)  was  most  marked  at 
the  base  of  the  brain  and  in  the  cerebellum  instead  of  over 
the  vertex,  as  in  the  typical  case  of  general  paralysis.  In 
one  such  case,  who  died  at  Morningside  Asylum,  Dr  J.  J. 
Brown  found  the  cord  degenerated,  not  only  in  its  posterior 
columns,  but  most  markedly  also  in  the  anterior  columns.  In 
that  case  the  medulla  oblongata  was  more  diseased  than  I 
ever  saw  in  any  other  case  of  any  kind.  Scarcely  a  single 
nerve  fibre  or  cell  seemed  to  me  normal. 

The  next  case  is  tlie  most  typical  of  six  cases  I  have  met  ivith, 
where  there  was  first  disease  of  tlie  retina,  and  then,  after  some 
years,  general  paralysis, 

G.  B.,  having  exposed  his  head  to  a  hot  sun  while  bathing, 
had  haemorrhage  into  both  retinae,  causing  complete  blindness. 
After  a  few  years  he  fell  into  general  paralysis,  and  when  he 
died  I  found  that  the  optic  nerves  were  hard  grey  cords,  with 
no  nerve  substance  left,  that  the  optic  tracts  were  in  the  same 
condition,  and  the  grey  sclerotic  degeneration  could  be  traced 


390  GENERAL   PARALYSIS. 

backwards  to  the  corpora  quadrigemina,  the  posterior  of 
which  were  grey  and  sclerotic.  The  evidences  of  cortical 
disease  were  strongest  at  the  base  of  the  brain,  the  convolu- 
tions of  the  anterior  lobes  over  the  orbital  plates  being 
specially  affected,  the  pia  mater  being  universally  adherent 
there. 

I  knew  a  gentleman,  G.  B.  A.,  ivlio  became  stone  deaf  in 
one  ear  several  years  before  he  developed  general  paralysis,  and 
though  I  had  no  pathological  proof  that  the  case  was  one  of 
propagation,  I  had  no  doubt  in  my  own  mind  on  the  subject. 
He  was  a  medical  man,  and  his  deafness  was  of  a  pecuHar 
character,  so  that  it  alarmed  him  very  much ;  and  when  the 
first  symptoms  of  general  brain  disease  appeared  he  said  he 
thought  it  was  just  the  extension  of  the  disease  from  his 
internal  ear.  Professor  Laycock  used  to  quote  a  case  of  his 
where  the  disease  had  spread  upwards  from  a  Wallerian  atrophy 
of  one  of  the  motor  nerves  of  one  of  the  fingers.  I  had  a  case, 
G.  D.,  a  woman  of  36,  who  passed  gradually  into  an  attack  of 
qidet  non-delusional  general  paralysis  after  a  small  punctured 
wound  in  the  top  of  her  head  penetrating  for  about  an  inch  into 
the  brain.  A  pitchfork  had  fallen  accidentally  on  the  top  of 
her  head  as  she  was  loading  a  cart  of  wheat.  After  death 
the  whole  of  the  convolutions  round  the  wound  were  found 
specially  affected,  though  the  cortex  in  most  parts  of  the 
vertex  and  sides  of  the  brain  were  affected  as  well. 

Symptomatological  Varieties. — There  are  many  cases  of 
paralysis  where  the  course,  and  even  the  nature,  of  the 
symptoms  vary,  within  Hmits,  exceedingly  from  the  typical 
symptoms  and  the  typical  course.  They  constitute  sympto- 
matological  varieties  of  the  disease.  The  most  common  and 
the  most  marked  of  these  is  the  non-delusional  variety,  as 
seen  in  the  following  case,  where  there  was  no  excitement, 
no  delusions  of  grandeur,  and  no  congestive  attacks,  but 
simply  a  gradual  mental  enfeeblement  beginning  Avith  the 
volitional  power,  and  a  gradual  paresis  beginning  with- 
muscular   weakness   and   fibrillar   trembhngs   in   the    facial 


GENERAL   PAEALYSIS.  391 

muscles  and  tongue,  this  gradually  passing  into  complete  inco- 
ordination. 

G.  C,  aet.  50.  A  quiet-living  man,  who  had  married  about 
three  years  before  he  became  affected  in  mind,  first  showed 
mental  defect  by  irresolution,  want  of  keen  interest  in  any- 
thing, forgetfulness,  and  the  want  of  a  realising  sense  of  the 
necessity  for  his  working  in  order  to  Hve.  Soon  he  got  a 
little  irritable  when  pressed  to  work.  Then  his.  mind  showed 
clear  signs  of  enfeeblement  and  facility.  He  would  believe 
silly  stories,  he  could  not  carry  on  a  connected  conversation, 
he  had  few  likes  or  dislikes.  I  saw  liim  at  this  stage,  and 
found  his  speech  thick,  his  hps  showing,  as  he  began  to  speak, 
that  fatal  quiver  that  to  a  practised  eye  almost  marks  the 
disease  from  all  others.  His  walk,  too,  was  not  firm,  and  in 
turning  round  sharply  he  did  so  uncertainly,  and  he  could 
not  walk  along  a  chalk  line  on  the  floor  or  stand  steadily  on 
one  leg.  He  gradually  got  more  enfeebled  and  frail  in  mind, 
his  speech  became  less  articulate  and  his  walk  more  paretic. 
[N'early  all  his  symptoms  were  negative.  He  had  a  gentle 
kleptomania.  He  would  pick  up  and  fill  his  pockets  with 
stray  pocket-handkerchiefs,  aprons,  and  rags  in  a  sort  of 
automatic  way,  not  in  the  least  caring  or  objecting  when 
they  were  taken  from  him.  He  died  in  six  years  of  pure 
exhaustion,  absolutely  paralysed,  never  having  made  a  sound 
that  could  be  called  articulate  for  a  year,  or  voluntarily  moved 
a  voluntary  muscle  during  that  time,  lying  on  a  water-bed, 
and  leading  a  merely  vegetative  life.  Such  cases  are  apt  to 
hve  a  long  time.  They  are  not  usually  caused  by  a  dissi- 
pated or  excited  life,  and  their  subjects  are  usually  of  a  calm 
plilegmatic  temperament.  Nearly  one-third  of  all  the  cases  of 
the  disease  that  I  have  seen  were  of  this  character,  and  nearly 
all  the  older  medical  officers  of  asylums  say  that  this  type  is 
increasing,  lohile  the  excited  grandiose  type  is  diminishing  in 
frequency.  This  type  is  very  common  in  the  female  sex ;  in 
fact,  the  majority  of  the  female  cases  conform  to  it  more  or 
less.     It   is  also  the  common  type  of   the   disease  in  those 


392  GENEKAL   PARALYSIS. 

parts  of  the  country  where  the  people  live  unexciting 
lives. 

Standing  at  the  opposite  point  from  this  quiet  form  of  the 
disease  are  the  two  varieties  of  which  I  shall  now  give 
examples.  The  first  is  the  specially  convulsive  form,  as 
exhibited  in  the  folloiving  two  cases: — 

G.  E.,  set.  about  40.  A  man  who  had  been  of  an  excitable 
disposition,  and  had  led  a  dissipated  Hfe  in  regard  to  drink 
and  women ;  of  a  fiery  temper ;  who  had  suffered  from 
syphihs ;  whose  whole  life  had  been  a  whirl  of  mental  excite- 
ment. He  had  complained  for  some  time  of  very  severe  head- 
aches, had  been  off  his  sleep,  had  been  unusally  irritable  and 
not  fit  to  do  a  day's  business.  One  day  he  suddenly  fell 
down  in  a  fit,  and  remained  in  general  and  severe  convulsions 
with  complete  unconsciousness  for  about  two  hours,  and  died  in 
them.  After  death  I  found  all  the  pathological  signs  of  general 
paralysis  :  especially  the  adherence  of  the  pia  mater  to  the  con- 
volutions of  the  vertex  in  patches  was  very  marked.  There 
was  no  local  disease  in  the  membranes  or  vessels  that  has 
been  recognised  as  syphilitic,  and  he  had  not  been  drinking 
heavily  before  his  death. 

My  conclusion  was  that  it  was  a  case  of  general  paralysis 
with  a  strongly  convulsive  tendency,  tliis  killing  the  patient 
before  the  usual  symptoms  had  time  to  develop.  I  do  not 
know  whether  I  should  or  not  have  been  able  to  diagnose  the 
case  had  I  seen  him  before  the  convulsive  attack,  or  whether 
there  were  any  motor  symptoms  present  before  it  occurred. 
But,  it  may  be  said — Is  it  possible  for  a  man  to  have  marked 
disease  of  the  brain  affecting  the  convolutions  of  the  vertex 
without  mental  or  motor  symptoms?  My  experience  of  the 
cases  of  general  paralysis,  who  died  as  G.  E.  did  early  in  the  first 
stage,  would  lead  me  to  the  conclusion  that  the  recognisable 
pathological  lesions  of  the  convolutions  precede  the  marked 
mental  symptoms.  They  usually  need  to  develop  in  some  in- 
tensity, and  to  involve  a  certain  number  or  hind  of  convolutions, 
before  mental  or  motor  symptoms  become  very  manifest. 


■    •'•  GENERAL   PARALYSIS,  393 

I  had  a  general  paralytic  in  the  Asylum,  G.  A.,  who  took  an 
epileptiform  convulsion  every  day  for  months.  The  tempera- 
ture rises  often  before,  and  always  after,  an  epileptiform  con- 
vulsion or  a  merely  congestive  attack  in  these  cases.  I  had 
another  patient  who  had  many  epileptic- looking  fits  for  a 
year,  and  was  treated  for  epilepsy  by  eminent  physicians 
during  that  time,  before  the  usual  mental  and  motor  signs  of 
general  paralysis  appeared. 

The  convulsive  tendency  is  best  treated  by  the  steady  use 
of  the  bromides,  which,  however,  always  aggravate  the  inco- 
ordination. During  a  congestive  attack  with  convulsions  they 
can  be  stopped  by  large  doses  of  chloral,  or  by  putting  the 
patient  under  chloroform ;  but  I  doubt  whether  consciousness 
is  sooner  regained  thereby,  or  if  life  is  prolonged. 

The  next  marked  departure  from  the  normal  type  of  general 
paralysis,  such  asT  have  described  it,  is  where  the  first  stage 
consists  of  maniacal  exaltation  alone,  without  any  motor  sign 
that  one  can  recognise,  for  months,  and  even  years.  I  have  had 
several  cases  now  who  had  what  appeared  to  be  attacks  of  ordi- 
nary acute  mania,  and  to  all  appearance  had  recovered,  who 
had  even  second  attacks  and  recovered,  and  then  developed 
the  motor  symptoms  of  general  paralysis.  The  following  is 
one  of  them  : — 

G.  G.,  set.  36,  an  Irishman  born — Irishmen  often  enough 
suffer  from  general  paralysis  here,  if  they  do  not  at  home — 
drunken  and  hard  working;  married.  Had  an  attack  of 
"acute  mania"  in  1876,  and  was  sent  to  the  Asylum,  and 
"recovered"  in  five  weeks.  No  motor  signs  nor  evidences  of 
general  paralysis  were  noted  by  me  or  any  one  else  then.  In 
1878  he  had  another  attack,  and  this  time  some  suspicion  of 
the  disease  was  excited,  but  no  diagnosis  made.  He  was  again 
discharged  recovered,  and  it  was  only  on  his  third  admission, 
three  years  after  his  first,  that  the  disease  was  manifest.  He 
died  of  it  in  three  years  after  his  last  admission. 

In  such  a  case  as  that  of  G.  G.  I  have  no  doubt  whatever 
that  the  first  attack  in  1876  was  really  a  part  of  the  general 


394  GENERAL  PAEALYSIS. 

paralysis,  but  at  that  time  the  disease  was  probably  super- 
ficial in  the  anterior  cortex  and  confined  to  a  limited  area, 
and  did  not  involve  to  any  extent  the  motor  centres  in  the 
convolutions,  causing,  no  doubt,  much  congestion  and  much 
vascular  overactivity  in  the  cortex,  but  not  inco-ordination  of 
motion.  The  first  attacks  were  brain-storms  that  passed  away, 
so  far  as  the  active  congestion  and  the  vascular  disturbance 
were  concerned,  leaving  the  incipient  organic  convolutional 
change  there,  but  quiescent.  I  have  also  no  doubt — in  fact, 
I  obtained  clear  evidences  of  it  from  his  wife — that  intel- 
lectually he  was  weakened  after  the  first  attack  of  "acute 
mania"  in  1876.  Such  cases  enable  one  to  understand  the 
"  recoveries  "  and  "  cures  "  .  of  general  paralysis,  not  one  of 
which,  I  beheve,  was  ever  real  or  lasting,  if  the  diagnosis  has 
been  correct. 

Do  not  diagnose  from  mental  symptoms  alone. — It  is  common 
to  have  in  the  beginning  of  the  first  stage  very  acutely 
maniacal  mental  symptoms,  and  no  apparent  motor  signs 
discovered — and  general  paralysis  should  never  be  diagnosed 
from  mental  symptoms  alone.  But  there  is  no  doubt  that 
the  mania  of  general  paralysis  is  the  most  intense — not  to 
be  incoherently  delirious, — the  most  unreasoning,  and  the 
most  exhausting  we  ever  see ;  and  to  the  experienced  eye 
it  has  a '  certain  character  of  its  own  in  most  cases  which 
suggests  the  disease. 

In  certain  cases  we  have  a  combination  of  the  non-delusional 
and  the  simply  maniacal  or  partially  maniacal  forms,  the 
patients  being  simply  irritable  or  semi-deUrious  at  night. 
I  had  a  case,  G.  H.,  who  was  acutely  maniacal,  very  danger- 
ous, very  homicidal,  very  impulsive,  and  very  strong-willed 
and  unmanageable  for  twelve  months  before  there  were 
any  motor  symptoms  that  enabled  me  to  diagnose  general 
paralysis.  From  the  state  of  his  pupils,  and  the  looks  and 
expression  of  his  face,  I  suspected  it,  but  I  could  not  have 
said  definitely  it  was  any  other  condition  than  acute  mania 
for  the  first  twelve  months. 


■    '  '  (GENERAL   PARALYSIS.  395 

It  is  very  uncommon  for  a  man  toho  suffers  from  general 
paralysis  to  have  been  insane  before,  but  I  have  met  with  a 
few  examples.  One,  G.  H.  A.,  had  an  attack  of  mania  in 
youth,  recovered,  kept  well,  and  did  liis  ordinary  business 
for  twenty  years,  and  at  the  age  of  forty-four  became  a 
general  paralytic. 

We  meet  with  certain  long-lived  cases  that  do  not  die  at  the 
normal  time,  hut  live  on  for  periods  up  to  thirty  years.  The 
following  is  the  most  marked  case  of  this  hind  on  record : — 

G.  J.,  set.  35,  admitted  to  the  Eoyal  Edinburgh  Asylum 
18th  November  1860.  Had  led  a  somewhat  rough  life, 
and  nine  months  before  had  an  "  epileptic  fit."  No  heredity 
to  insanity,  but  he  had  a  very  eccentric,  somewhat  silly 
sister.  The  attack  had  been  preceded  by  a  melancholic 
condition,  and  he  had  refused  his  food.  His  articulation  was 
slurred,  his  pupils  unequal,  his  walk  slow  and  unsteady. 
He  was  unhesitatingly  diagnosed  as  a  general  paralytic. 
After  nine  months  he  was  taken  out  of  the  Asylum  by  his 
relatives,  but  had  to  be  sent  back  again  in  eighteen  months, 
having  been,  while  outside,  totally  unable  to  do  anything 
for  his  own  livelihood,  and  having  got  gradually  worse  in 
mind  and  body.  When  admitted  in  1863  he  was  "stout, 
stupid,  and  silent,"  had  the  "peculiar  expression  of  face  of 
general  paralysis  well  marked,  as  well  as  its  walk."  Some 
days  he  was  "  quite  well  and  happy."  In  a  few  months 
he  was  "  uproariously  happy,"  with  the  most  exaggerated 
notions  about  his  riches,  strength,  height,  beauty,  &c.  He 
is  40  feet  high,  is  God,  is  married  to  the  Queen,  is  the 
strongest  man  in  the  world,  and  has  a  "damnable  heap  of 
money."  All  Leith  Docks  belonged  to  him,  and  most  of 
the  ships  there.  In  December  1863  he  had  a  series  of 
epileptiform  fits,  which  were  ushered  in  by  a  regular  con- 
gestive attack.  He  became  very  weak,  and  could  with 
difficulty  articulate  or  make  his  water.  He  got  over  tliis 
condition  in  a  few  weeks,  and  became  facile  and  contented. 
An  assistant  physician  of  the  Asylum  recorded,  in  the  Case- 


396  GENEEAL   PARALYSIS. 

Book  in  1864, — "Is  a  magnificent  specimen  of  a  general 
paralytic."  In  June  1864  lie  had  a  congestive  attack, 
succeeded  by  epileptiform  fits,  being  maniacal  and  restless 
afterwards.  In  August  1864  he  had  another  congestive 
attack,  and  one  in  January  1865,  and  got  so  frail  in  March 
that  he  had  to  be  kept  in  bed.  In  March  he  had  another 
congestive  attack.  He  had  no  congestive  or  epileptiform 
attack  again  till  December  1880.  During  all  these  years 
the  symptoms  remained  the  same,  but  the  disease  did  not 
advance  much  till  after  the  epileptiform  attack  in  1880. 
The  period  of  general  convulsion  was  short,  only  a  few 
minutes,  but  he  was  confused  and  stupid  afterwards  for  four 
hours,  and  was  then  excited  and  noisy.  The  paresis  in- 
creased after  this,  and  the  general  strength  failed  much. 
In  February  1881  he  had  another  severe  attack  of  general 
convulsions,  with  several  hours  of  unconsciousness  following 
them,  the  temperature  rising  to  102*4°  in  three  hours,  and  then 
faUing  to  normal  in  two  hours  after  that.  He  had  two  such 
attacks  in  April  of  that  year.  After  the  last  the  left  side 
was  found  weaker  than  the  right,  and  he  was  shaken 
generally.  During  the  summer  he  could  not  walk  far  with- 
out becoming  paralysed  in  his  legs ;  he  had  incontinence 
of  urine,  his  speech  was  thicker  and  less  articulate,  and 
mentally  he  was  more  facile  and  stupid. 

In  1887,  twenty-eight  years  after  the  commencement  of 
his  illness,  his  condition  was  as  follows  : — Facial  expression 
vacant;  pupils  both  contracted,  but  partially  sensitive  to 
light,  the  left  being  slightly  the  larger,  outlines  not  regularly 
circular ;  tongue  tremulous,  and  its  muscles  inco-ordinated 
over  surface ;  articulation  affected  just  like  that  of  a  typical 
general  paralytic  in  end  of  second  stage  of  the  disease,  difficult 
words  being  worse  pronounced,  and  the  ends  of  sentences 
worse  than  their  beginning ;  walk  uncertain,  dragging,  strad- 
dling ;  sensibility  diminished,  can  smell  pepper,  but  cannot 
be  made  to  sneeze ;  spinal  reflexes  very  acute,  patellar  tendon 
reflex  quite    absent.     Often   has   retention   of   urine.     Can- 


•    •'•  GENERAL   PARALYSIS.  397 

not  walk  well ;  turns  round  with  difficulty  ;  cannot  stand 
on  one  leg ;  whole  nutrition  flabby  ;  mentally  in  a  facile, 
morbidly  contented,  exalted  state. 

In  1889  he  had  an  attack  of  unconsciousness,  with  a  period 
of  mental  confusion  afterwards.  He  retained  his  grandiose 
delusions,  his  irritability,  and  his  kleptomaniacal  tendencies. 
His  articulation  got  more  and  more  slurred,  but  had  not  .then 
in  any  marked  degree  the  shakiness  and  quavering  of  the 
typical  general  paralytic.  In  1890  he  became  almost  inarticu- 
late ;  witliin  eight  days  of  his  death  he  collected  in  his  pockets 
leaves,  flowers,  dirty  paper,  rags,  old  iron,  stones,  broken 
plaster,  and  wood.  He  became  feverish  four  days  before  his 
death,  wliich  took  place  on  the  29th  July  1891,  ove?-  thirty 
years  since  the  commencement  of  his  disease. 

The  following  pathological  report  of  Ms  case  is  by  Dr 
Middlemass  : — 

"  The  skull-cap  showed  slight  general  thickening,  especially 
of  the  inner  table,  but  the  bone  was  soft  rather  than  dense.  ■ 
The  dura  mater  was  adherent  to  it  over  a  small  area  in  the 
region  of  the  frontal  eminences,  and  the  Avhole  membrane  was 
thickened  and  rougher  than  normal.  On  its  inner  surface 
there  Avas  marked  'rusty  staining,'  but  no  membrane.  The 
cerebro-spinal  fluid  was  much  increased  both  in  the  sub-dural 
and,  to  a  greater  degree,  in  the  sub-arachnoid  spaces.  The 
pia-arachnoid  was  considerably  thickened,  and  presented  .a 
milky  appearance,  but  it  was  nowhere  adherent  to  the  grey 
matter  of  the  cortex.  There  was  very  marked  atrophy  of  the 
convolutions,  especially  of  the  frontal  region.  Instead  of  their 
usual  rounded  appearance,  they  were  wedge-shaped,  but  flattened 
on  the  top,  some  even  had  a  slight  depression  running  along 
the  outer  surface.  The  sulci  were  wide  and  gaping,  and  the 
ventricles  considerably  dilated.  There  were  numerous  small 
granulations  on  the  ependyma  of  the  ventricles.  The  pia  mater 
of  the  cerebellum  was  not  apparently  thickened  nor  adherent 
to  the  grey  matter. 

"  Microscopic  Apptearances. — As  regards  the  microscopic  ap- 


398  .  GENEEAL  PAEALYSIS. 

pearances  of  fresh  sections  of  the  cortex,  those  seen  in  one 
from  the  anterior  part  of  the  frontal  region  may  be  described 
first.  The  pia  mater  was  considerably  thickened,  and  in  the 
cortical  layer  immediately  subjacent  to  it  there  were  numerous 
spider  cells.  These  for  the  most  part  were  small,  not  well 
stained,  and  nearly  all  exhibited  signs  of  fatty  degeneration. 
The  vessels  were  prominent,  partly  from  an  increase  of  the 
adventitial  nuclei,  partly  also  from  a  deeper  than  usual  stain- 
ing of  the  material  forming  their  walls.  In  the  deeper  and 
larger  vessels  there  was  a  shght  deposit  of  pigment  and  fatty 
particles  m  the  perivascular  spaces.  The  nerve-cells  of  the 
second  and  third  layers  showed  evidences  of  marked  granular 
and  slight  pigmentary  degeneration,  the  protoplasm  being 
irregularly  stained  and  many  of  the  processes  gone.  In  many 
of  the  nuclei  there  were  one  or  two  small  fatty  globules,  and 
in  a  few  vacuolation  even  had  occurred.  The  large  pyramidal 
cells  of  the  fourth  layer  shoAved  decided  pigmentary  degener- 
ation, and  in  many  there  were  fatty  granules.  The  cells  of 
the  remaining  layers  were  not  so  much  degenerated.  In  this 
region,  however,  there  was  an  increase  in  the  nuclei  of  the 
neurogha  cells,  and  a  dense  fibrillation  of  the  neuroglia,  due 
to  the  dehcate  processes  of  very  numerous  spider  cells.  These 
were  small,  and  stained  shghtly.  Many  were  fatty,  and  most 
of  them  showed  signs  of  degeneration  or  feeble  vitahty. 

"  Sections  from  Broca's  convolution  indicated  a  greater 
degree  of  thickening  of  the  pia,  an  increased  number  of 
spider  cells  subjacent  to  it,  and  more  pronounced  degenera- 
tion of  the  nerve  cells. 

"  In  the  ascending  frontal  convolution  the  thickening  of  the 
pia  mater  was  ehght,  but  the  cellular  degeneration  was  still 
marked. 

"In  sections  from  the  sensory  regions  the  pial  tliickening 
was  not  appreciable,  the  nerve  ceUs  of  the  two  deepest  layers 
were  only  slightly  degenerated,  and  the  spider  cells  in  this 
level  almost  absent." 

So  far  as  I  am  aware,  no  case  with  every  mental  and  bodily 


.  '.-.  GENERAL   PARALYSIS.  399 

symptom  of  general  paralysis,  and  diagnosed  by  many  com- 
petent and  experienced  specialists  to  be  sucli,  ever  lived  so 
long  as  thirty  years.  Dr  Blandford^  relates  such  a  case  who 
lived  twenty-seven  years.  I  have'  known  many  cases  that 
lived  over  ten  years ;  and,  if  ten  years,  why  not  thirty  1 
Nature  goes  far  in  her  exceptions  to  most  pathological  "rules" 
on  a  few  rare  occasions.  It  may  be  said — Was  not  tliis  a  case 
of  alcohohc  or  syphilitic  brain  damage  to  the  mental  and 
motor  constituents  of  the  cortex  that  was  not  really  progres- 
sive, which  merely  caused  brain  atrophy,  and  that  the  patient 
died  of  old  age  ?  If  that  is  so,  we  are  landed  in  the  awkward 
dilemma  that  we  may  have  every  symptom  of  general  paralysis 
during  life,  and  every  pathological  change  in  the  brain  after 
death,  except  adhesion  of  the  pia  mater  to  the  convolutions, 
and  yet  not  the  disease  itself,  because  the  patient  lived  beyond  . 
the  hitherto  recorded  time.  As  our  knowledge  of  the  disease 
has  advanced,  we  have  seen  that  it  is  found  at  early  ages  and 
at  late  ages.  I  cannot  see  any  valid  reason  why  liitherto  un- 
precedented duration  should  upset  the  conclusion  founded  on 
clinical  and  pathological  evidence. 

The  non-adherence  of  the  pia  opens  out  very  interesting 
pathological  questions  in  regard  to  the  disease.  Had  it  so 
adhered  in  the  early  stages  of  the  disease,  but,  through  cortical 
shrinkage,  absorption  of  pathological  products,  and  fatty  de- 
generation of  spider  eeUs  during  the  long  course  of  the  case, 
had  the  adherence  disappeared,  leaving  the  other  pathological 
changes  still  present  1  I  believe  this  to  have  been  the  case. 
It  is  consistent  with  the  experience  of  other  cases,  and  with 
the  known  laws  of  the  absorption  of  pathological  products ; 
and  Bevan  Lewis  ^  thinks  there  is  undoubted  evidence  that 
this  process  of  disappearance  of  pial  adhesions  takes  place. 
Instead  of  the  exalted  condition  of  mind,  or  the  merely  en- 
feebled and  facile  one,  we  have  a  few  cases — from  3  to  4  per 
cent,   in   my   experience — with   melancholic   symptoms.     My 

^  Insanity  and  its  Treatment,  3rd  ed. ,  p.  299. 
2  Op.  cit.,  p.  488. 


400  GENERAL   PAEALYSIS. 

belief  and  experience  is  that  in  almost  all  these  there  is  some 
organic  visceral  disease  or  disturbance  which  transmits  to  the 
convolutions  sensations  that  are  disagreeable  and  depressing. 
On  examination  of  our  pathological  register,  I  found  that 
nearly  all  the  cases  that  had  tubercular  disease  had  been 
melanchohc.  I  had  a  man,  G.  K.,  who  had  the  fixed 
melancholic  delusion  that  a  man  was  inside  him  who  annoyed 
him  constantly,  and  this  made  him  depressed.  After  death 
we  found  tubercular  disease  of  the  intestines.  I  have  a 
most  instructive  case  now  showing  the  influence  of  visceral 
disease  on  the  mental  condition  of  a  general  paralytic,  G.  L., 
a  cabman,  who  thought  on  admission  he  had  £30,000,  and 
got  £1000  from  Queen  Victoria  for  driving  her  along  Princes 
Street.  Suddenly  one  day  he  became  melanchohc,  saying  he 
was  a  beggar,  and  crying  bitterly.  We  examined  his  chest 
and  found  he  had  bronchitis.  The  reflex  action  was  so  dulled, 
as  in  most  cases  of  the  disease,  that  he  had  no  cough,  felt  no 
pain,  and  made  no  complaint.  As  Ms  bronchitis  improved, 
his  mental  elevation  and  delusions  of  grandeur  returned.  He 
had  a  relapse,  and  the  melancholic  state  at  once  came  back. 
For  a  week  or  so  he  was  elevated  one  day  and  depressed  the 
next.  At  last  the  bronchitis  was  recovered  from,  and  he  is  the 
happy  imaginary  possessor  of  his  thousands.  'WHienever  I  see 
a  general  paralytic  dull  now,  I  always  search  for  an  organic 
visceral  cause,  and  usually  find  it. 

I  had  one  case  of  the  disease,  G.  M.,  that  began  with 
aphasia,  and  was  treated  for  several  months  for  this.  As 
he  began  to  speak  the  pecuhar  articulation  was  noticed,  and 
he  died  in  about  two  years.  In  his  case,  the  motor  reflex  ex- 
citabihty  of  the  brain  and  cord  was  greater  than  I  ever  saw 
in  any  case  whatever.  A  very  slight  tap  on  the  toe  would 
set  lip  a  convulsion  first  in  that  leg,  and  then  in  the  next; 
a  slight  puff  suddenly  into  his  face  would  make  liim  jump 
off  his  seat  with  liis  whole  body.  I  have  many  times  seen 
general  paralytics  aphasic  after  congestive  attacks.  In  such 
cases,  and  in  all  cases  where  the  speech  was  specially  affected 


■    •  ■  GENERAL   PARALYSIS.  401 

during  the  disease,  I  have  always  found  after  death  that  the  third 
frontal  convolution  of  the  left  side  and  the  region  of  the  brain 
round  it  had  the  pia  mater  especially  adherent  to  the  cortex. 

I  have  lately  seen  several  cases  of  what  I  have  called 
"developmental  general  paralysis"'^  The  disease  is  very  rare 
before  the  age  of  twenty-five,  but  a  few  cases  had  been  re- 
ported— one  by  myself  in  1877 — at  ages  from  twelve  to 
twenty.  Two  such  cases  were  placed  under  my  care  in  1890, 
in  both  of  whom  the  first  symptoms  of  this  disease  had  shown 
themselves  at  fifteen,  and  in  both  followed  a  typical  course  till 
they  died,  the  one  at  the  age  of  seventeen  and  the  other  at 
twenty.  Both  were  girls  who  had  never  menstruated,  and 
were  undeveloped  and  girlish  in  form  and  appearance.  Both 
had  a  neurotic  heredity,  and  both  had  hereditary  syphilis. 
The  pathological  appearances — naked  eye  and  microscopic — 
found  in  the  brains  of  both  were  typical,  and  taken  along  with 
the  symptoms  during  life  left  no  doubt  whatever  as  to  the 
nature  of  the  disease.  My  conclusion  is  that  the  disease  may 
occur  as  one  of  the  great  and  varied  groups  of  the  neuroses  of 
development  in  subjects  with  a  strong  neurotic  heredity. 

The  special  senses  are  always  more  or  less  affected  sooner 
or  later,  but  commonly  later.  Most  cases  cannot  distinguish 
between  substances  having  different  tastes  when  the  disease 
is  advanced.  Some  become  blind,  some  are  deaf,  and  many 
lose  the  sense  of  smell.  This  is  caused,  I  believe,  by  a 
primary  degeneration  in  the  cortical  centres  of  special  sense, 
and  a  secondary  degeneration  in  the  nerves  of  special  sense 
and  their  terminal  nerve  apparatus.  These  latter  can  be 
demonstrated  in  many  cases,  the  optic  nerves  in  some  being 
like  grey  fibrous  cords.  The  eye  symptoms  generally  are 
most  important  in  this  disease.  They  are  chiefly  oculo- 
motor, but  the  expression  of  the  eye  is  entirely  changed, 
there  being  an  expression  difficult  to  describe  wliich  is  very 
pathognomonic  of  the  disease.  The  patient  lacks  vivacity 
of  look,  and  the  cornea  is  dull  and  lifeless,  in  this  respect 
^  The  author's  Neuroses  of  Development. 

2  c 


402  GENERAL   PAEALYSIS. 

being  entirely  different  from  acute  mania.  The  changes  in 
the  pupils  are  marked  in  most  cases.  There  is  commonly 
contraction,  sometimes  up  to  pin-point  condition,  in  the  first 
stage.  This  sometimes  lasts  all  through  the  disease.  There 
is  in  hy  far  the  majority  of  cases  inequahty  of  the  pupils,  one 
of  which  does  not  react  either  to  hght  or  to  accommodation  so 
well  as  the  other.  In  many  cases  there  is  dilatation,  and  tins 
is  the  more  common  condition  in  the  second  stage  and  in  the 
quiet  gradual  class  of  cases.  Then  the  outUne  of  the  pupil  is  com- 
monly irregular  in  contour  from  irregular  motor  innervation. 

Bevan  Lewis  points  out  the  delayed  reaction-time  in  the 
disease.  This  together  with  the  dulled  reflexes  is,  in  my 
opinion,  the  reason  why  so  large  a  proportion  of  the  cases  of 
broken  ribs  in  asylums  are  general  paralytics.  "Whien  the 
chest  is  struck  or  the  weight  of  another  patient  or  an  atten- 
dant is  thrown  on  it,  the  laryngeal  muscles  do  not  act  in  time 
to  close  the  chest  and  make  it  resistive,  through  its  being 
filled  with  air  that  cannot  be  driven  out. 

I  have  only  seen  one  patient  in  whom  long-continued 
ordinary  insanity  became  changed  into  general  paralysis.  It 
was  a  case  of  dementia  of  twelve  years'  standing.  It  was 
an  exception  that  proves  the  rule  that  general  paralysis  and 
ordinary  insanity  have  httle  in  common  pathologically. 

The  conditions  that  are  most  apt  to  he  mistaken  for  general 
paralysis  are  alcoholism,  syphihtic  insanity,  paralytic  insanity, 
certain  cases  of  epileptic  insanity,  certain  cases  of  brain 
tumour,  acute  mania  with  ambitious  delusions,  choreic 
insanity,  some  senile  conditions,  some  traumatic  cases,  and 
some  cases  of  imbecihty  with  stuttering  speech.  It  is  quite 
impossible  to  diagnose  correctly  at  once  some  cases  of  alco- 
holism from  general  paralysis.  We  must  wait  in  such  cases. 
!Never  diagnose  general  paralysis  till  you  are  sure.  I  have 
met  with  two  cases  of  traumatism  where  the  symptoms  were 
chiefly  those  of  general  paralysis,  but  the  cases  hved  on  and 
died  of  diseases  not  cerebral. 

Inception, — General  paralysis  does  not  commonly  begin  by 


GENERAL  PARALYSIS.  403 

a  sudden  appearance  of  any  of  those  motor  or  marked  mental 
symptoms.  If  a  correct  history  of  the  patient's  mental  state 
for  two  or  three  years  before  the  "  insanity  "  openly  showed 
itself  can  be  obtained,  we  will  usually  find  premonitory  symp- 
toms in  the  shape  of  sensory  neuroses,  diminished  energy, 
changed  disposition,  lack  of  enjoyment  of  life,  depression,  or 
some  other  mental  change  indicating  weakened  nervous  ener- 
gising. In  many  cases  I  think  the  middle-aged  general 
paralytic  is  suffering  for  the  sins  of  his  youth. 

Causation. — There  are  two  causes  that,  singly  or  combined, 
above  all  others,  cause  the  disease,  viz.,  sexual  excess,  espe- 
cially if  indulged  in  at  or  after  middle  life,  and  alcoholic 
intemperance,  especially  if  impure  and  bad  drinks  are  used. 
If  hard  work,  muscular  or  mental,  with  a  stimulating  diet 
of  flesh,  are  combined  with  these,  then  we  have  an  additional 
liability.  Some  recent  continental  authors  assign  syphilis  as 
the  real  cause  of  the  disease,  and  Dr  Drummond  of  Newcastle 
homologates  this  view.^  I  cannot  agree  with  it  because  I  have 
had  many  cases  in  which  the  existence  of  personal  syphilis 
was  excluded  by  every  sort  of  rehable  evidence.  But  mental 
shocks  and  strains  of  all  sorts  will  of  themselves  cause  the 
disease.  There  is  a  certain  temperament  that  predisposes  to 
it — the  intensely  sanguine.  Dr  G.  E.  Wilson  contends  that 
there  is  a  "  diathesis  of  general  paralysis,"  and  adduces  very 
many  pertinent  facts  in  favour  of  this  view.  "  General 
intelligence,"  "  ambition  and  energy,  sociability  and  a  large 
capacity  for  enjoyment,  a  firm  belief  in  oneself,  and  a  prefer- 
ence for  handsome  women,"  are  the  good  and  sane  character- 
istics of  this  diathesis,  while  a  lack  of  the  higher  control, 
tendencies  to  excess,  especially  sexual  excess,  selfishness, 
vanity  and  restlessness,  are  its  weak  points.^  This  accentu- 
ates the  above  causes  of  brain  irritation  and  exhaustion. 
Hereditary  predisposition  to  insanity  or  to  the  neuroses  is  less 

^  Brit.  Med.  Jour.,  5th  August  1893. 

"^  Jour.  Men.  Set.,  Jan.  1892,  "The  Diathesis  of  General  Paralysis," 
by  G.  KWilson,  M.B. 


404  GENERAL   PAEALYSIS. 

common  in  this  disease  than  in  the  ordinary  forms  of  insanity. 
But  lately  I  had  a  general  paralytic  patient,  and  Dr  Savage 
had  his  twin  brother,^  there  being  a  strong  family  history  of 
insanity,  both  men  being  of  the  same  temperament  and  dis- 
position, viz.,  sanguine  and  keen,  both  being  of  very  active 
habits,  both  indulging  to  great  excess  in  wine  and  women, 
both  following  a  similar  occupation,  an  exciting  one,  and  both 
being  affected  by  the  disease  within  a  year  of  one  another. 
Such  a  chnical  history  has  never  been  put  on  record  before, 
and  it  shows  conclusively  that  heredity  may  predispose  to  the 
disease.  The  idea  is  gaining  ground,  however,  that  hereditj^ 
either  mental  or  neurotic,  has  more  to  do  with  the  develop- 
ment of  the  disease  than  was  formerly  supposed. 

Age. — The  common  age  for  the  occurrence  of  the  disease  is 
between  25  and  50.  The  chart  in  Plate  V.  shows  its  pre- 
valence in  104  cases  admitted  to  this  Asylum  as  compared 
with  mania  and  melanchoha,  and  the  ages  at  which  it  occurred. 
The  greatest  number  of  cases  occurred  between  40  and  45 
years.  But  there  are  a  few  exceptional  patients.  I  have 
referred  to  the  "developmental"  cases  (p.  401),  and  I  have 
lately  had  a  case  beginning  at  66  years  of  age,  the  diagnosis 
being  confirmed  by  post-mortem  examination. 

Pathological  Appearances  in  the  Brain  in  General  Paralysis. 
— At  this  point  I  tliink  it  is  better  to  supplement  the  clinical 
history  of  the  disease  by  describing  very  shortly  the  patho- 
logical appearances  met  with  in  the  brain.  It  is  a  subject  of 
supreme  importance  and  interest  not  only  for  the  psychiatric 
department  of  medicine,  but  for  every  branch.  When  we 
know  fully  the  pathology  of  this  disease  and  that  of  epilepsy, 
we  shall  be  very  near  the  solution  of  the  chief  problems  of 
mental  disease  and  of  many  social  facts  now  very  obscure. 
The  encasings  and  supports  of  the  organ  are  all  found  to  be 
affected,  and  the  longer  the  case  has  lasted  the  more  marked 
are  the  changes  met  with.  The  bone  of  the  calvarium  is 
denser  and  harder,  in  many  cases  the  diploe  being  obliterated, 
^  Jour.  Ment.  Science,  vol.  xxxiv.  p.  65. 


•    ■'•  GENERAL  PAEALYSIS.  405 

and  in  many  others  there  is  a  distinct  layering  and  deposit 
of  new  bone  on  the  inside  of  the  inner  table  of  the  skull-cap, 
this  being  usually  confined  to  the  frontal  and  parietal  bones. 
The  dura  mater  is  thickened,  adheres  more  or  less  morbidly, 
and  frequently  leaves  shreds  attached  to  the  bone.  In  many 
cases  I  have  seen  spicula  of  bone  growing  in  it  at  the  junction 
of  the  f  alx,  which  is  always  much  thickened.  When  the  dura 
mater  is  reflected,  the  most  characteristic  morbid  appear- 
ances of  the  disease  are  seen.  I  have  endeavoured  to  depict 
some  of  them,  as  seen  in  a  very  advanced  case,  in  Plate  I. 
(see  Frontispiece). 

In  a  number  of  the  cases  we  find,  under  the  dura  mater, 
and  attached  to  it,  lying  between  it  and  the  arachnoid,  a  new 
substance  of  a  morbid  and  pecuhar  kind,  commonly  called  a 
false  membrane.  It  varies  in  consistence  from  a  hard  fibrous 
texture  to  a  jelly,  in  colour  from  a  dull  greyish-white  to  that 
of  blood  clot,  in  thickness  from  a  film  to  a  quarter  of  an  inch, 
in  extent  from  a  small  patch  or  two  to  a  covering  of  both 
hemispheres  above  and  below.  It  is  usually  thickest  over 
the  vertex.  In  some  cases  it  looks  like  a  clot,  in  others  like 
an  extra  layer  of  dura  mater,  but  it  can  always  be  easily 
scraped  away.  When  it  is  removed  from  the  dura  mater 
that  membrane  is  commonly  not  congested  nor  inflamed  look- 
ing. It  always  contains  new  blood-vessels,  and  nearly  always 
blood-corpuscles  or  blood-colouring  matter.  Drs  Middlemass 
and  Robertson^  have  devoted  much  attention  to  the  investiga- 
tion of  this  condition.  They  conclude  that  it  is  not  inflamma- 
tion and  not  hsemorrhagic  in  the  ordinary  sense,  but  that  for 
its  formation  we  must  previously  have  "  a  hyaline  degeneration 
of  the  vessels  and  their  perivascular  canals  which  leads  to  the 
obliteration  of  both.  While  the  vessels  are  undergoing  this 
morbid  change  small  haemorrhages  frequently  occur  from  them. 
Their  obliteration  is  followed  by  the  formation  of  new  capil- 
laries which  are,  doubtless,  required  to  maintain  the  nutrition 
of  the  fibrous  tissue.  From  these  new  vessels,  the  formation 
1  Edin.  Med.  Joxhr.,  February  1895.  ■ 


406  GENERAL   PARALYSIS. 

of  whicli  is  necessarily  accompanied  hj  the  development  of  a 
certain  amount  of  granulation  tissue,  further  minute  haemor- 
rhages occur.  The  extravasated  blood  becomes  the  basis  of  more 
granulation  tissue.  These  changes  are  at  first  subendothelial, 
but  the  extending  granulation  tissue  soon  breaks  its  way 
through  this  barrier,  and  a  membrane  becomes  developed." 
But  I  must  refer  to  the  full  and  elaborate  description  by  those 
gentlemen.  This  is  the  so-called  pachymeningitis  hoemorrhagica 
inter7ia  of  the  Germans,  a  ridiculous  and  misleading  name,  for 
it  is  not  the  result  of  inflammation  at  all.  The  formation  of 
the  substance  is,  to  my  mind,  full  of  interest  and  instructive- 
ness.  Its  formation  implies,  I  believe,  a  very  great  intensity  of 
morbid  action  in  the  convolutions,  vascular  disease,  and 
above  all,  great  and  sudden  changes  in  the  blood  pressure 
witliin  the  cranium. 

Under  the  membrane  if  present,  and  under  the  dura  mater 
if  not  present,  we  see  in  very  well  marked  advanced  cases 
the  appearance  presented  in  Plate  I.  b.  on  the  anterior  lobe. 
The  arachnoid  is  immensely  thickened,  and  either  mottled 
with  white  spots  or  striated  along  the  sulci  with  white  fibrous- 
looking  bands.^  Under  it  there  is  what  looks  Hke  a  dull 
opaque  jelly,  through  which  the  convolutions  dimly  appear, 
and  under  which  great  tortuous  congested  veins  meander, 
some  of  these  being,  perhaps,  if  the  case  has  died  during  or 
after  a  congestive  attack,  obstructed  by  little  white  masses 
of  hard  ante-mortem  clot.  But  this  is  not  really  a  jelly,  for  if 
the  arachnoid  is  pricked  it  nearly  all  oozes  out  as  a  dirty 
opaque  fluid,  that  amounts  to  from  2  to  10  ounces  in 
quantity.  This  is,  in  my  opinion,  a  compensatory  fluid,  filling 
up  the  space  left  vacant  by  the  atrophy  of  the  convolutions 
and  brain  generally.  It  does  not  nearly  represent  the  whole 
of  the  brain  atrophy,  for  we  have,  in  addition,  enlarged  ven- 

1  For  a  full  and  accurate  description  of  the  pathological  process  that 
takes  place  in  the  pia-arachnoid  in  such  cases  I  must  refer  to  Drs 
Middlemass  and  Robertson's  original  investigations  as  described  in  the 
Edin.  Med.  Joicr.  for  April  and  May  1895. 


■    •'•  GENERAL  PARALYSIS.  407 

tricles  and  dilated  perivascular  spaces,  which  often  contain 
6  ounces   more  of   fluid.     But  the  advocates  of   the  theory 
that  this  disease  is  an  inflammation  in  its  essence,  look  on 
tliis  fluid  as  an  inflammatory  product,  and  consider  that  its 
presence  causes  pressure  within  the  cranium,  and  this  again 
causes  irritative  maniacal  symptoms,  and  ultimately  atrophy 
of   the   convolutions.     To  relieve   this  hypothetical  pressure 
Drs  Clay  Shaw  and  Batty  Tuke  have  trephined  the  skulls  of 
patients  labouring  under  the  disease,  and  opened  the  dural 
space.     After  the  fluid  has  drained  ofi",  the  pia  mater  and  the 
convolutions  are  better  seen.     Both  are  strikingly  abnormal. 
The  pia  mater  is  thickened,  vascular,  and  tough  to  an  enor- 
mous extent.     The  convolutions  are  atrophied,  especially  over 
the  vertex  of   the  anterior  and   middle   lobes  and   in  some 
localised  places  elsewhere,  and  generally  tend  to  be  wedge- 
shaped,  and  He  loosely  together.     When  the  pia  mater  is  re- 
moved from  the  convolutions — do  this  in  every  case  of  mental 
disease   you   examine, — it   is  found   to  adhere   to  and  raise 
up  portions  of  the  outer  layer  of  the  grey  substance  on  the 
ridges  of  the  convolutions — seldom  in  the  sulci — which  stick 
to  the  pia  mater,  are  removed  with  it,  and  appear  as  irregular 
patches  over  the  membrane  that  has  been  detached  from  the 
brain   (see  lower  part  of  Plate  I.).     The  convolutions  from 
which  those  patches  have  been  removed  look  eroded,  like  the 
surface  of  a  cheese  where  a  mouse  has  been  (see  middle  portion 
of  Plate).     Now,  this  adhesion  of  the  pia  mater  to  the  con- 
volutions is  a  very  morbid  phenomenon.     It  has  never  been 
found  to  any  extent  in  any  patient  whose  mind  was  sound 
and  strong  before  death.     It  is,  in  different  cases,  confined  to 
a  few  convolutions,  or  general  over  all  the  brain.     It  is  by 
far  most  frequently  confined  to  the  vertex  and  to  the  anterior 
and   middle   lobes,  to   the  convolutions  of   the  hemispheres 
lying  in  contact  with  each  other  above,  below,  and  in  front 
of  the  anterior  part  of  the  corpus  callosum,  and  to  the  gyri 
round  the  olfactory  bulbs  at  the  base.     Its  greatest  intensity 
is   evidently  different   in  different   cases,  so   that   it   affects 


408  GENERAL   PAEALYSIS. 

different  areas.  This  corresponds  to  the  clinical  fact  that  in 
one  general  paralytic  the  speech  will  be  most  affected,  in 
another  the  writing,  in  another  the  walking,  and  in  another 
the  tropliic  power.  I  have  seen  two  cases  now  in  which 
gangrene  of  the  Hmbs  occurred  from  pure  trophic  nerve 
failure.  The  two  hemispheres  usually  adhere  anteriorly,  and 
in  the  attempt  to  separate  them  some  of  the  substance  of 
the  convolutions  will  be  torn  away.  In  some  cases  we  find 
this  adhesion  of  the  pia  mater  at  the  base,  over  the  orbital 
convolutions  and  the  middle  lobes.  I  have  seldom  seen  the 
tips  of  the  posterior  lobes  much  affected.  They  are  usually 
healthy  looking.  Though  the  adhesion  is  only  partial  in  most 
cases,  I  have  seen  it  almost  universal.  It  merely  represents, 
in  my  opinion,  the  acme  of  a  pathological  process  that  is  very 
general  in  the  convolutions.  In  examining  the  different  con- 
volutions of  the  brain  of  a  general  paralytic  microscopically, 
and  the  different  parts  of  one  convolution,  we  find  that, 
though  the  morbid  appearances  are  in  greater  intensity  in  one 
place  than  another,  they  by  no  means  coincide  in  absolute 
intensity  with  the  parts  to  which  the  pia  mater  has  adhered. 
I  have  found  as  much  disease  microscopically  in  a  convolution 
to  which  it  did  not  adhere  as  in  those  to  which  it  did.  There 
is  rarely  or  ever  much  adherence  of  the  pia  mater  that  dips 
down  into  the  sulci,  and  I  have  never  seen  one  convolution 
adhering  to  the  next.  This  fact  has  always,  in  my  judgment, 
gone  to  prove  that  the  disease  is  not  of  inflammatory  origin, 
using  that  word  in  its  ordinary  sense.  The  fact  is,  that  the 
pia  mater  that  dips  in  and  separates  adjoining  convolutions 
is  different  in  composition  and  use  from  that  portion  that 
overlies  the  whole  brain.  The  former  contains  fewer  lym- 
phatics, and  is  a  mere  fine  network  of  fibres  to  hold  the 
vessels,  while  the  latter  is  full  of  lymphatic  spaces. 

On  section  the  grey  matter  of  the  convolutions  affected  is 
often  divided  into  two  distinct  layers,  the  outer  being  grey 
and  opaque  looking,  and  there  is  often  a  line  of  red  congestion 
as  the  demarcation  between  those  two.     Along  this  line  the 


■    ."•  GENERAL   PARALYSIS.  409 

brain  tissue  seems  softer  and  more  pultaceous.  There  is  no 
real  sclerosis,  though,  on  the  whole,  the  outer  layer  of  the 
grey  substance  may  be  slightly  harder  in  texture  than  normal. 
In  some  cases,  however,  it  is  distinctly  softer.  The  whole 
grey  matter  is  thinner,  especially  in  the  cases  that  have  lasted 
long.  The  white  substance  is  often  very  congested,  especially 
in  irregular  patches  (as  seen  in  Plate  IV.),  its  perivascular 
spaces  are  always  enlarged,  and  the  small  vessels  tough  and 
their  coats  thickened. 

On  opening  into  the  ventricles  they  are  nearly  always  found 
enlarged,  but  the  most  striking  pecuHarity  is,  that  their 
normally  delicate  epithelial  linings  are  toughened  and 
roughened  in  an  extraordinary  degree.  Their  surfaces  look 
in  the  less  marked  cases  like  frosted  glass,  in  the  more  marked 
cases  they  are  granular,  and  even  minutely  nodular,  feehng 
rough  to  the  touch.  They  are  leathery,  too,  when  torn.  This 
condition  is  usually  most  marked  in  the  floor  of  the  fourth 
ventricle,  and  the  covering  of  the  calamus  scriptorius  is 
always  a  greyish,  gelatinous-looking,  but  really  tough  mem- 
brane. The  microscopic  examination  of  a  section  of  such  a 
granulation  at  once  shows  what  has  taken  place  (see  Plate 
II.  fig.  3).  The  single  normal  layer  of  delicate  epithelium 
has  become  enormoiisly  hypertrophied,  and  in  addition,  the 
neuroglia  underneath  it,  and  for  a  short  distance  down  into 
the  nerve  fibres,  or  cells,  has  become  hypertrophied  in  limited 
areas,  throwing  itself  up  in  masses,  thus  constituting  the  bulk 
of  the  granulations. 

Microscopic  Appearances. — The  microscopic  appearances  in 
the  brain  in  general  paralysis  have  been  the  subject  of  the 
most  careful  examination  by  some  of  the  best  modern  histol- 
ogists.  Meynert,  Mendel,  Y.  Gudden,  Yoisin,  and  many 
others  abroad,  and  Batty  Tuke  and  Mickle  in  this  country, 
have  all  greatly  advanced  our  knowledge ;  but  it  was  not 
until  Bevan  Lewis  devised  his  method  of  examining  and 
staining  fresh  sections  of  brain  that  the  morbid  changes  could 
be  followed  in  each  constituent  tissue  of  the  diseased  cortex 


410  GENERAL   PARALYSIS. 

and  througli  tlie  various  stages  of  tlie  disease.  In  tlie  chapter 
on  the  "Pathological  Anatomy  of  General  Paralysis,"  in  his 
Text-Book  of  Mental  Diseases,  we,  for  the  first  time,  have 
opened  out  to  us  the  main  facts  on  which  a  pathology  of  the 
disease  can  be  based.  Most  of  Lewis'  facts  are  indisputable 
and  of  supreme  importance.  His  interpretation  of  some  of 
them  admits,  perhaps,  of  difi"erence  of  opinion,  at  all  events 
on  some  points. 

I  shall  first  shortly  summarise  Lewis'  facts,  almost  all  of 
which  I  may  say  we  have  been  able  to  confirm  in  the  patho- 
logical laboratory  of  the  Eoyal  Edinburgh  Asylum  through 
Drs  Middlemass  and  Eobertson,  the  pathologists  here,  using 
Lewis'  methods.  During  the  first  stage  of  the  disease,  in  acute 
cases,  there  is  great  "  turgescence  of  the  vessels  of  the  pia,"  and 
"great  distension  and  engorgement  of  the  cortical  arterioles." 
"  The  perivascular  lymph  channels  are  the  site  of  a  nuclear  pro- 
liferation and  segmentation  of  protoplasm,  often  so  enormous  as 
to  entirely  conceal  the  inclosed  vessel  from  view."  Lewis  has 
thrown  an  entirely  new  light  on  the  lymphatic  system  of  the 
cortex,  both  in  its  histological,  physiological,  and  pathological 
aspects.  In  the  first  stage  of  the  disease,  which  he  calls  that 
of  "inflammatory  engorgement,"  he  says  Kttle  about  the 
condition  of  the  nerve-cells,  which  after  all  constitute  the 
tissue  for  which  everything  else  in  the  cortex  exists,  !N"ext, 
there  is  a  "notable  increase  in  the  nucleated  protoplasmic 
cells  of  the  adventitia  of  the  vessels  of  the  pia,  together  with 
a  general  though  slight  proliferation  of  the  most  superficial 
flask-shaped  cells  of  the  peripheral  zone  of  the  cortex  and  the 
vessels  of  the  intima  pia  resting  upon  it."  Prom  these  cells 
of  the  pia  long  delicate  processes  are  sent  out  extending 
deeply  into  this  layer.  ISText,  there  is  "  a  very  free  exudation 
into  the  meshes  of  the  pia."  The  vessels  lose  their  support 
through  atrophy  of  the  cortex,  and  there  is  in  consequence  a 
"strong  tendency  to  hsemorrhagic  transudation  or  to  actual 
rupture  and  haemorrhage." 

The  second  stage  is  characterised  by  a  further  enormous 


GENERAL   PARALYSIS.  411 

production  of  protoplasmic  masses  on  the  walls  of  the  lymph 
channels  in  the  perivascular  canals  within  the  substance  of 
the  cortex,  by  a  granular  change  in  the  nerve-cells,  which  is 
succeeded  by  a  fuscous  degeneration  and  breaking  down 
into  granular  debris.  Then  comes  the  most  striking  of  all 
the  marked  changes.  The  ultimate  cells  of  the  lymph  con- 
nective system  which  have  direct  connection  with  the  walls 
of  the  capillaries  and  minute  vessels  by  means  of  fine  pro- 
cesses, become  enormously  enlarged  and  developed.  Instead 
of  being  fine  spider-like  cells  (Deiter's  cells)  they  become  the 
"  phagocytes  "  or  scavengers  of  the  tissue,  because  the  usual 
lymph  channels  have  become  blocked  up,  and  they  enlarge 
accordingly  both  in  cell  and  cell  process  until  in  a  section 
they  seem  to  be  the  dominatuig  element  of  the  cortex  (see 
Plate  VIII.  fig.  1  a.a.).  "  Occasionally  several  of  these  active 
elements  are  seen  completely  covering  a  large  nerve-cell 
which  is  in  an  advanced  stage  of  decay,"  removing  its 
disintegrating  substance  filled  with  its  molecular  debris. 
"They  are  usually  noted  in  great  abundance  in  the  deeper 
half  of  the  peripheral  or  outermost  layer  of  the  cortex." 
The  medullated  nerve-fibres  of  the  cortex  are  found  to  be 
undergoing  absorption  as  well  as  the  cells,  as  had  been 
previously  clearly  described  and  figured  by  Tuczek.^ 

In  the  third  stage  these  prohferated  spider-cells  throw  out 
innumerable  fine  processes  that  form  a  fibrillar  meshwork, 
and  the  nerve-cells  further  degenerate  and  atrophy.  In  fact 
a  sclerosis  and  general  atrophy  take  place.^ 

Lewis'  explanation  of  those  morbid  changes  in  the  cortex 
is  that  we  have  a  true  inflammatory  process  arising  first 
in  the  vascular  tissues  of  the  pia,  through  which  the  blood- 
vessels are  damaged,  the  lymph  channels  are  obstructed, 
all  the  tissues  undergo  mechanical  and  vital  changes,  the 
nerve-cells  suffering  in  nutrition  through  those  changes  in 

1  Bertrdge  zur  Path.  Anatomie  u.  zur  Pathologic  de  Dementia  Paralytica. 

2  The  appearances  of  the  diseased  cells  and  vessels  will  be  seen  in 
Plates  XIIL,  XIV.  and  XV. 


412  GENEEAL   PARALYSIS. 

the  vessels  "wliich  bring  their  pabulum,  and  in  the  lymphatics 
that  remove  the  prodncts  of  metabolism  in  their  texture. 
He  contends  against  Mierzejewski's  view  that  the  morbid 
process  in  the  cells  is  "inflammatory  in  its  intrinsic  nature." 
He  'Svholly  fails  to  recognise  an  inflammatory  condition 
in  the  cells  themselves,  but  sees  the  evidence  of  a  true 
degeneration  due  to  acute  nutritional  anomalies,"  and  he 
"fails  to  observe  any  notable  difference  between  the  changes 
through  which  these  cells  pass,  and  those  of  the  cortex  in 
senile  atrophy,  except  in  the  greater  tendency  to  a  true 
steatosis  in  the  latter  state."  It  is  always  an  invidious  thing, 
that  should  never  be  lightly  done,  to  put  a  diff'erent  interpre- 
tation on  the  facts  discovered  by  a  competent  and  acute 
investigator.  But  the  physiology  and  the  pathology  of  the 
brain  cortex  is  as  yet  so  backward  that  it  cannot  injure 
the  ultimate  truth  to  put  forward  a  diff'erent  explanation  of 
Lewis'  facts.  My  view  is  that  general  paralysis  is  not 
essentially  an  inflammation  of  the  pia,  extending  to  the  cortex, 
through  Avhich  the  brain  cells  are  secondarily  disturbed  and 
ultimately  killed,  but  that  it  is  a  special  and  distinctive 
disease  of  the  mind  cortex  primarily,  the  cells  of  which  take 
on  a  morbid  nutrition  and  energising,  and  secondarily  cause 
the  vascular  and  lymphatic  changes.  My  reasons  for  this 
view  are  the  following,  which,  it  must  be  understood,  are 
put  as  succinctly  as  possible. 

1.  The  chief  causes  of  the  disease  are  nervous  and  mental, 
so  far  as  we  can  assign  them,  e.g.,  sexual  excess,  alcoholic 
poisoning,  bodily  and  mental  strain  and  exhaustion,  &c. 

2.  The  course  of  the  disease  is  that  of  a  typical  nerve 
degeneration  in  the  highest  and  dominating  centre  of  all,  it  is 
steadily  progressive,  and  affects  aU  the  lower  and  subsidiary 
centres  in  a  steady  progressive  way,  the  cord,  the  retina,  the 
peripheral  nerves,  the  sympathetic  gangha,  and  the  whole 
trophic  system. 

3.  At  the  beginning  of  many  other  nervous  degenerations 
and  dissolutions  there  is  a  preliminary  stage  of  irritation  and 


GENEEAL  PAKALYSIS.  413 

qnasi-inflammatory   symptoms,    e.g.,   locomotor   ataxia ;   and. 
even .  senility  often  has  such  a  stage. 

4.  The  occasional  high  temperature  in  the  first  stage  of 
general  paralysis  can  be  explained  by  its  being  a  maniacal 
temperature,  and  is  often  equalled  in  uncomplicated  acute 
mania.  It  seldom — apart  from  congestive  attacks — rises  to 
a  true  inflammatory  temperature. 

5.  The  vascular  congestion  and  subsequent  lymphatic  changes 
can  be  satisfactorily  explained  through  the  vaso-motor  and 
tropliic  centres  in  the  cortex  being  affected.  The  cortex  is  now 
generally  recognised  to  regulate  its  own  blood-supply  through 
the  vaso-motor  centres  which  exist  throughout  its  substance. 
It  is  well  known  that  mental  exertion,  mental  irritation  and 
excitement  determine  blood  to  the  cortex.  No  one  thinks  of 
such  congestions  as  being  inflammation. 

6.  The  morbid  process  never,  in  any  one  case,  goes  on  to 
form  ordinary  inflammatory  products  such  as  pus. 

7.  There  are  many  cases  of  the  disease — one-third — in 
which  there  is  no  first  stage  of  mental  excitement  or  ir- 
ritability, or  high  temperature,  or  headache,  or  any  symptom 
pointing  even  to  congestion  of  the  membranes  or  cortex. 
The  clinical  aspect  of  such  cases  is  that  of  a  slowly  advancing 
loss  of  function  of  the  cortex. 

8.  Looking  to  the  history  of  the  examination  of  the  brain 
cortex,  it  seems  a  far  more  reasonable  assumption  that  by  our 
present  methods  of  examination  we  are  not  yet  able  to  demon- 
strate the  changes  in  the  cells  in  the  earliest  stages  of  the 
disease,  while  the  changes  in  the  coarser  tissues,  such  as  the 
blood-vessels  and  lymphatic  system,  being  far  easier  seen, 
seem  to  be  the  first  pathological  changes,  when  in  reality  they 
are  secondary  and  resultant. 

9.  Every  individual  pathological  change  described  by  Be  van 
Lewis,  can  be  seen  in  other  varieties  of  brain  disease,  e.g., 
brain  syphiHs,  softenings,  alcoholic  damage,  senile  changes, 
traumatic  injuries,  yet  these  are  admittedly  distinct  from 
general  paralysis  in  their  nature  and  course. 


414  GENERAL  PAEALYSIS. 

10.  If  it  was  an  inflammation  there  would  surely  be  some 
exceptional  cases  that  would  recover.  Its  universal  incura- 
bility agrees  with  the  theory  of  its  being  a  specific  degenera- 
tion or  disease  of  the  special  cortical  tissue,  that  is,  the  vehicle 
of  mind,  and  which  brings  mind  into  relationship  with  motion, 
but  does  not  agree  with  the  inflammatory  theory. 

11.  The  universal  vascular  and  trophic  changes  throughout 
the  course  of  both  carotids,  as  evidenced  by  the  liability  to 
hsematoma,  by  the  "false  membranes,"  by  the  nutritive 
changes  in  the  ear  cartilages,  the  skull  bones,  in  the  dura,  in 
the  epithelial  linings  of  the  brain,  are  best  explained  by  a 
morbid  action  of  the  vaso-motor  centres  in  the  cortex  which 
control  both  carotids  rather  than  by  a  local  inflammatory 
action  arising  in  the  pia. 

12.  This  is  not  a  question  of  terms  merely.  The  advocates 
of  the  view  that  the  disease  is  in  its  essence  a  degeneration 
of  the  highest  cortical  centre  admit  that  the  lymphatic  and 
vascular  changes  are  indistinguishable  from  inflammation  in 
the  appearances  seen,  but  contend  that  these  are  secondary 
and  non-essential.  The  advocates  of  the  inflammatory  theory 
admit  the  degeneration  and  atrophy  of  the  cortex,  but  contend 
that  those  are  secondary.  The  degeneration  theory  is  based 
on  the  whole  etiological,  clinical,  and  pathological  history  of 
the  disease ;  the  inflammatory  theory  is  based  almost  exclu- 
sively on  visible  pathological  changes  in  the  vascular  and 
lymphatic  elements  of  the  cortex. 

There  is  no  nervous  tissue  that  is  not  found  diseased  and 
degenerate  in  advanced  cases  of  the  disease, — the  cord,  the 
retina,  the  peripheral  nerves,  the  sympathetic  ganglia,  &c. 
Dr  Greenlees  has  shown  that  hypertrophy  of  the  heart  is 
frequent  in  this  disease,  no  doubt  caused  by  the  disturbed 
innervation  of  the  organ  and  the  blood-vessels.  As  I 
first  demonstrated  many  years  ago,  the  bones  are  friable, 
and  altered  in  texture  and  composition  from  the  same 
cause. 

Nature  and  Causes  of  the  Disease. — What,  then,  is  general 


GENERAL   PARALYSIS.  415 

paralysis  ?  There  are  few  diseases  whose  essential  nature  we 
as  yet  know.  But  we  know  that  the  special  trophic  energy 
and  inherent  physiological  qualities  of  different  tissues  become 
perverted  in  special  ways,  so  that  most  tissues  have  their  own 
special  types  of  disease.  There  can  be  no  doubt  that  the  grey 
substance  of  the  convolutions  of  the  brain  of  man  is  the  high- 
est in  quality  and  function  of  any  organic  product  yet  known 
in  nature.  That  substance  reaches  its  highest  development 
in  the  male  sex  between  adolescence  and  middle  hfe.  Its 
uses  are  called  forth  in  the  highest  degree  in  the  European 
races  who  live  in  towns.  Its  physiological  abuses  by  alcoholic 
and  other  poisoning,  by  over-strain,  by  violent  energising 
stimulated  by  continuous  strong  mental  and  other  stimuli  up 
to  the  point  of  exhaustion,  are  also  most  common  under  those 
circumstances.  Its  outer  layers  are  most  delicately  con- 
stituted, have  far  more  blood,  more  fine  fibres  and  more  minute 
cells  than  any  other  portion  of  the  brain,  and,  on  the  whole, 
may  be  regarded  as  the  most  important  factor  in  mentahsation, 
being  in  fact  the  mind  tissue.  Immediately  underlying  it  in 
the  convolutions,  in  certain  parts  of  the  brain,  we  have  what 
are  probably  the  motor  cells.  This  outer  rind  of  grey  matter, 
to  which  tend  fibrils  from  every  neuron,  is  precisely  that 
affected  first  in  general  paralysis.  The  proof  goes  to  show  that 
all  the  other  nervous  degenerations  which  finally  affect  the 
whole  nervous  system  are  subsequent  and  sequential.  Granted 
a  progressive  and  incurable  disease  of  this  mind  tissue,  towards 
which  the  whole  of  the  rest  of  the  nervous  system  tends 
and  in  which  it  ends,  which  controls  and  regulates  it  all,  and 
which  is  its  crown  and  highest  development,  the  highest  and 
dominating  centre  of  the  organism,  it  is  quite  explicable  that 
all  the  rest  of  the  nervous  system  should  degenerate  in  struc- 
ture and  function,  and  in  fact  die  slowly  and  progressively. 
It  is  a  quality  of  nerve  tissue  to  degenerate  in  the  lines  of 
physiological  activity,  and  in  this  disease  we  have  the  best 
illustration  of  the  law.  General  paralysis  is  a  disease  of  this 
outer  layer  of  the  cerebral  convolutions — of  the  mind  tissue. 


416  GENERAL   PARALYSIS. 

in  fact  a  special  and  absolutely  distinctive  disease  of  that 
tissue,  and  peculiar  to  it.  In  many  other  diseases  we  have 
adhesion  of  the  pia  mater  to  the  convolutions,  but  in  none 
the  element  of  certain  progression  of  neurine  degeneration. 
It  is  essentially  a  death  of  that  tissue.  I  look  on  it  as  being 
equivalent  to  a  premature  and  sudden  senile  condition,  senility 
being  the  slow  physiological  process  of  ending,  general  paralysis 
the  quick  pathological  one.  The  causes  of  it  are  causes  that 
have  exhausted  trophic  energy  by  over-stimulation.  Its  first 
stage  is  accompanied  by  undoubted  morbid  vaso-motor  dilata- 
tion, so  that  all  the  tissues  enveloping  the  brain,  and  holding 
its  elements  together,  receive  an  abnormal  supply  of  blood, 
and  thereby  acquire  tissue  hypertrophy — the  bones  of  the 
skull-cap,  the  membranes,  the  neurogha,  the  lymphatics,  the 
epithelium,  and  the  vessels.  Just  as  the  tissue  degenera- 
tions, especially  the  brain  degenerations  of  old  age,  cannot 
be  arrested,  and  are  necessarily  progressive,  so  is  general 
paralysis.  Those  high  nerve  cells  have  lost  their  once  in- 
herent power  of  seH-restoration,  and  so  they  degenerate  and 
atrophy.  The  diseased  process  is  pecuUar  because  the  tissue 
in  which  it  originates  is  peculiar. 

Treatment  of  General  Paralysis. — The  disease  being  as  yet 
incurable,  treatment  can  only  be  directed  towards  rehef  of 
symptoms.  But  considering  that  in  the  early  stage  of  many 
cases  it  is  impossible  to  make  the  diagnosis  certainly  as 
between  this  disease  and  brain  syphihs  or  alcoholism,  I  would 
in  all  such  cases  give  large  doses  of  the  iodide  of  potassium 
with  about  -^  grain  of  bichloride  of  mercury,  with  blisters  or 
other  counter-irritation  to  the  scalp,  keeping  the  patients  on 
the  medicine  for  six  weeks  or  so.  I  have  now  met  with  many 
cases  who  had  almost  all  the  early  symptoms  of  the  disease 
and  recovered.  I  have  no  doubt  they  were  cases  of  brain 
syphilis.  To  subdue  or  modify  the  acute  and  dangerous 
maniacal  excitement  of  the  first  stage,  I  have  found  no  drug 
equal  to  sulphonal  in  doses  of  from  20  to  4.5  grains  repeated 
thrice  daily  till  the  patient  was  got  under  the  influence  of  the 


GENERAL  .PARALYSIS.  417 

drug,  and  then  tlie  doses  diminished  in  number  sufficiently  to 
keep  the  patient  under  the  influence  of  the  drug.  If  for  the 
first  week  or  so  of  treatment  the  patient  is  mostly  kept  in  a 
quiet  darkened  room  the  eff'ect  will  be  all  the  better.  I  have 
had  many  cases  in  which,  after  a  few  weeks  of  this  treat- 
ment, the  patients  passed  into  a  more  quiet  state  and  remained 
so.  Lately  Drs  Clay  Shaw,  Batty  Tuke  and  Macpherson  have 
reported  great  improvement  after  trephining,  and  the  first  re- 
ports a  virtual  cure.  Of  the  cure  I  am  most  sceptical,  but  the 
■  operation  can  now  be  done  with  little  risk  and  seems  worth  try- 
ing further.  I  have  tried  it  with  no  success.  Almost  anything 
is  worth  trying  in  this  Mte  noir  of  the  mental  physician.  For 
the  treatment  of  the  epileptiform  attacks  a  smart  purge  and  a 
few  doses  of  the  bromide  of  potassiuin  seem  to  me  the  best  to 
stop  the  convulsions  when  they  are  very  severe  and  long  con- 
tinued. I  have  tried  large  doses  of  chloral  and  putting  the 
patients  under  chloroform,  with  the  result  usually  of  tem- 
porarily stopping  the  convulsions,  but  I  noticed  that  several 
of  the  patients  seemed  none  the  better  of  having  the  convul- 
sions stopped,  and  died  very  soon.  In  the  third  stage  bed- 
sores are  the  great  risk  and  trouble  in  nursing  the  disease. 
Keeping  the  skin  dry,  hardening  it,  frequent  changes  of 
position  to  change  the  points  of  pressure,  keeping  the  patients 
sitting  during  the  day  in  easy  invalid  chairs  instead  of  keeping 
them  in  bed,  and  finally  the  use  of  water-beds  are  the  chief 
means  now  used.  Most  general  paralytics  need  asylum 
treatment,  but  there  are  a  few  who  get  through  the  various 
stages  of  their  disease  at  their  homes,  and  die  comfortably 
there. 

Local  Distribution. — General  paralysis  prevails  in  some 
places  and  in  some  races,  and  is  almost  unknown  in  others. 
As  yet  the  Asiatic  is  not  subject  to  it,  the  savage  in  the  savage 
state  is  free  from  it,  and  the  Irishman  and  Scotch  Highlander 
need  to  come  to  the  big  towns  or  to  go  to  America  to  have  the 
distinction  of  being  able  to  acquire  it.  The  female  sex  is  very 
unsusceptible  to  it,  but  if  women  drink  much  bad  liquor  and 

2  D 


418         '  PAEALYTIC   INSANITY. 

live  riotous  excited  lives,  as  in  the  cotton  and  manufacturing 
districts  of  England,  tliey  too  will  become  general  paralytics. 
I  liave  only  seen  three  females  in  the  rank  of  ladies  suffering 
from  general  paralysis.  In  this  country  the  Durham  miner, 
when  earning  good  wages,  fulfils  the  most  perfect  conditions 
yet  known  for  the  production  of  general  paralysis.  Every 
sixth  lunatic  admitted  to  the  Durham  County  Asylum  is  a 
general  paralytic.  In  the  Eoyal  Edinburgh  Asylum,  which 
draws  its  pauper  inmates  from  the  city  of  Edinburgh  and  its 
private  patients  from  all  classes  and  all  districts,  every  seven- 
teenth admission  during  ten  years  has  been  a  general  paralytic  ; 
and  in  the  Inverness  and  Irish  District  Asylums  the  admission 
of  a  case  is  a  rare  event. 


PAEALYTIC  INSANITY— ORGANIC  DEMENTIA. 

From  "Softenings"  in  83  per  cent.,  causing  direct  cortical  damage, 
destruction  of  "  Association  fibres,"  or  reflex  irritation,  or  all  three 
— also  from  Apoplexies,  Tumours,  Atrophies,  Chronic  Degenera- 
tions, &c.  ;  Heredity — Symptoms  vary,  but  always  Dementia — 
Motor  Restlessness,  analogy  to  Senile  Insanity,  Speech — Tumours 
may  cause  Irritability,  hallucinations,  suspicions,  dementia,  stupor, 
speech  affected  like  General  Paralysis  in  some  cases  ;  paralytic,  con- 
gestive, and  epileptiform  attacks — Paralytic  Insanity  3  per  cent,  in 
Eoyal  Edinburgh  Asylum — 19  per  cent,  recover. 

Paralytic  Insanity,  or  Organic  Dementia,  is  that  form  of 
mental  disturbance  that  accompanies  and  results  from  such 
gross  brain  lesions  as  apoplexies,  ramoUissements,  tumours,- 
atrophies,  and  chronic  degenerations  of  the  brain,  affecting 
the  convolutions  and  their  functions  either  primarily  or 
secondarily.  It  has  nothing  whatever  to  do  with  general 
paralysis.  Its  symptoms  vary  according  to  the  position,  kind, 
and  intensity  of  the  pathological  process,  and  the  age  and 
heredity  of  the  patient.     But  it  is  typically  a  dementia,  an 


PAEALYTIC  INSANITY.  419 

enfeeblement,  a  lessening  of  tlie  mental  power,  usually 
superadded  to  some  sort  of  motor  paralysis.  Preceding  this 
enfeeblement  there  may  be,  and  there  usually  is,  a  certain 
amount  of  depression  or  impulsiveness  at  first,  followed  after- 
wards by  a  mild  exaltation  and  emotionalism  of  a  childish 
kind,  and  loss  of  control,  this  gradually  passing  off  and 
leaving  the  patient,  if  he  lives  long  enough,  forgetful,  help- 
less, and  torpid.  Paralytic  insanity,  like  general  paralysis, 
has  a  gross  and  demonstrable  pathological  basis,  but  it  differs 
widely  and  essentially  from  it  in  not  being  a  specific  disease 
of  the  brain  convolutions,  in  not  running  a  progressive  course, 
in  the  mental  symptoms  not  being  necessarily  incurable,  in 
the  irregularity  and  variety  of  the  mental  symptoms  present, 
and  of  the  pathological  lesions.  It  is  best  and  most  commonly 
seen  in  a  case  where  there  has  been  apoplexy  from  rupture 
of  a  blood-vessel  in  one  of  the  great  basal  ganglia,  or 
embolism,  or  thrombosis,  followed  by  local  starvations  of 
brain  tissue  and  ramollissement ;  those  destructive  processes 
cutting  off  areas  of  the  convolutions  by  destroying  part  of 
the  projection  and  association  systems  of  fibres  by  which 
the  convolutions  are  brought  into  connection  with  the  basal 
ganglia,  the  cerebellum,  the  cord,  and  the  muscles,  or  with 
each  other.  This  interruption  may  of  itself  sensibly  affect 
the  mental  power,  and  those  pathological  processes  tend  to 
advance  up  into  the  convolutions^  so  destroying  the  sources 
of  mental  energy  directly,  A  brain  affected  by  apoplexy  or 
embohsm,  and  in  that  case  probably  having  its  blood-vessels 
generally  diseased,  is  an  organ  on  the  verge  of  dissolution. 
Such  processes  are  the  beginning  of  the  end  in  most  cases, 
and  the  mental  symptoms  are  often  the  most  prominent  and 
by  far  the  most  troublesome.  Yet,  after  all,  they  are  not 
the  essential  part  of  the  disease.  This  disease  is  often  not 
an  insanity  in  the  popular  acceptation.  In  many  cases  the 
gradual  mental  decay  is  never  thought  of  as  a  mental  disease 
at  all.  It  is  rather  looked  on  as  a  necessary  and  natural 
accompaniment  of  the  bodily  disease.     In  most  cases  it  is  not 


420  PARALYTIC   INSANITY. 

at  all  beyond  the  ordinary  nursing  capacity  and  management 
available  in  the  patient's  home,  if  he  has  any  money  or 
relatives  at  all.  The  very  poor  in  the  great  towns,  when 
affected  by  it,  are  sent  to  workhouses,  and  not  usually  to 
asylums  for  the  insane.  It  is  only  the  worst  and  most 
troublesome  cases  that  it  is  necessary  to  send  there — the 
noisy,  the  restless  at  night,  the  very  dirty,  the  troublesome. 
Motor  restlessness,  and  noise,  especially  at  night,  is  a  special 
characteristic  of  the  worst  class  of  cases,  and  this  often  needs, 
for  the  protection  of  the  patient,  special  nursing  and  special 
rooms.  But  there  is  no  essential  difference  between  the 
helpless  hemiplegic  whose  memory  is  gone,  his  energy  im- 
paired, his  thinking  capacity  paralysed,  and  his  affective 
power  deadened,  who  sits  in  his  easy-chair  at  home,  and 
the  restless,  shouting,  sleepless  paralytic  insane  man  in  the 
hospital  ward  of  an  asylum". 

Heredity. — The  heredity  of  the  patient  plays  an  important 
part  in  the  origination  of  paralytic  insanity  of  the  more 
marked  kind.  While  a  man  with  no  nervous  heredity  may 
have  a  large  spot  of  softening  in  one  of  his  corpora  striata, 
he  yet  may  be  calm,  reasonable,  and  quite  manageable, 
though  forgetful,  torpid,  and  emotional,  while  the  man  with 
a  bad  nervous  heredity  will  become,  under  the  same  con- 
ditions, restless,  depressed,  noisy,  and  sleepless.  There  is 
no  doubt  that  apoplexies  and  all  sorts  of  other  gross  limited 
lesions  produce,  in  unstable  brains,  great  convolutional  dis- 
turbance through  reflex  excitation.  If  such  brains  are 
unstable  in  their  motor  centres  we  have  convulsions,  local 
or  general;  if  there  is  hereditary  mental  instability,  then 
we  have  the  ordinary  symptoms  of  mania  or  melanchoha, 
I  had  once  as  a  patient  a  young  woman  (G.  IS".)  under  30, 
who,  having  heart  disease,  became  hemiplegic  on  her  right 
side,  aind  aphasic  after  the  birth  of  a  child.  Immediately 
after  these  great  mental  depression  came  on,  with  suicidal 
tendencies,  for  which  she  had  to  be  sent  to  the  Asylum. 
The  hemiplegia   soon   passed   quite   away,   but   the  aphasia 


.PARALYTIC  INSANITY.  421 

remained  all  her  life ;  and  when  the  mental  depression  passed 
off.  in  a  few  months  she  gradually  became  exalted,  and 
remained  so  for  some  months.  Then  she  again  became 
depressed,  and  was  mentally  a  typical  case  of  alternating 
insanity  {folie  circulaire)  for  the  seven  years  she  lived  after 
this.  She  at  last  died  of  the  heart  disease,  and  I  found 
Broca's  convolution  almost  destroyed  by  an  old  embolism, 
but  the  rest  of  the  brain  showed  only  the  results  of  repeated 
excitations  and  congestions.  In  this  case,  which  I  mention 
as  being  a  very  rare  and  most  unusual  kind  of  paralytic 
insanity,  the  embolism  and  its  consequences  no  doubt  excited 
into  pathological  activity  a  previously  existing  hereditary 
weakness  of  the  mental  portions  of  the  convolutions  which 
had  before  that  been  stable  in  their  working.  In  the  more 
typical  cases  of  paralytic  insanity  the  same  thing  occurs  in 
old  and  partially  worn-out  brains. 

Relationship  of  Paralytic  and  Senile  Insanities. — There  is  a 
close  analogy  in  symptoms,  pathology,  and  course  between 
paralytic  and  senile  insanity.  In  fact,  the  majority  of  para- 
lytic cases  are  also  senile,  and  in  many  cases  we  are  at  a 
loss  whether  they  are  senile  or  paralytic.  In  a  brain  with 
general  senile  degeneration  and  diseased  arteries,  a  local 
lesion  occurs,  and  we  have  it  exciting  and  lighting  up  a 
general  convolutional  flame.  I  have  had  many  cases  where 
there  was  a  family  tendency  to  mental  disease,  but  it  haid 
never  shown  itself  in  any  actual  symptoms  till  the  very  end 
of  life,  when  an  attack  of  paralysis  occurred,  and  this  was 
followed  by  melanchoHc  or  maniacal  symptoms  and  sub- 
sequent dementia.  I  have  had  several  such  patients  whose 
children  had  become  insane  at  an  early  age  long  before  them, 
they  remaining  well  till  they  became  hemiplegic.  One  such 
case  was  G,  0.,  eet.  67,  who  remained  quite  well  mentally, 
and  did  his  work  till  he  had  a  slight  attack  of  left  hemiplegia. 
Then  he  became  melancholic,  sleepless,  and  suicidal,  and 
had  to  be  sent  to  the  Asylum,  where  his  daughter,  G.  P.,  had 
been   a  patient  for   thirteen  years,   suffering  from  essential 


422  PAEALYTIC   INSANITY. 

paralysis   of   infancy   on   the   right  side,   epilepsy,    and   de- 
mentia. 

Motor  Symptoms. — The  motor  symptoms  in  paralytic  in- 
sanity must  be  regarded  as  integral  parts  of  the  disease. 
The  speech  is  the  most  characteristic  of  these  in  the  ordinary 
hemiplegic  cases.  It  is  a  thick  or  paretic  articulation,  not 
commonly  a  tremulous  speech.  Every  word  from  the 
beginning  of  a  sentence  to  the  end  is  imperfectly  pronounced. 
The  labial  and  facial  muscles  do  not  quiver  before  or  during 
the  articulatory  process,  as  in  'general  paralysis,  though  the 
tongue  usually  trembles  when  put  out.  It  is  a  simple  paretic, 
not  a  convulsive  speech.  Long  difficult  words  and  sentences 
are  attempted,  and  got  through  in  a  way,  but  are  not  found 
impossible  of  attempt,  or  end  in  a  mere  inarticulate  quavering 
vowel  sound,  as  often  occurs  in  general  paralysis.  In  the 
latter  disease  it  is  essentially  a  convolutional-lesion  speech; 
in  the  former  it  is  the  speech  of  a  lesion  in  the  basal  motor 
ganglia,  or  of  gross  limited  lesion  in  the  cortex.  In  the 
former  it  is  the  originating  motor  speech  co-ordinations 
of  the  convolutions  that  are  affected,  in  the  latter  the 
secondary  co-ordinations  lower  down.  In  very  many  of 
the  paralytic  cases  we  have  apoplexies  and  similar  lesions 
of  the  convolutions  themselves,  and  in  such  the  speech 
symptoms  are  always  more  like  those  of  general  paralysis. 
In  such  patients,  too,  we  are  apt  to  have  epileptiform,  epilep- 
tic, and  congestive  attacks.  In  many  instances,  even  when 
the  original  lesion  has  been  in  the  corpora  striata  or  in  the 
motor  fibres  of  conduction  near  it,  destruction  of  tissue  or 
atrophy  will  go  on  up  to  the  convolutions;  in  fact,  if  the  patient 
lives  long  enough  it  is  sure  to  do  so,  and  the  speech  will 
become  more  like  that  of  the  second  stage  of  general  paralysis. 
I  need  hardly  say  that  if  the  lesion  affects  the  posterior 
portion  of  the  third  frontal  convolution  of  the  left  side,  or 
the  Island  of  E,eil  on  that  side,  or  the  fibres  of  communica- 
tion inwards  from  those  parts,  or  certain  portions  of  the 
extra-ventricular  nucleus  of  the  corpus  striatum  of  that  side 


PAKALYTIC   INSANITY.  423 

— in  such  cases  we  will  have  aphasic  speech  symptoms. 
It  i^  a  disputed  question  whether  complete  aphasia  can 
coexist  with  perfect  integrity  of  the  intellectual  faculties. 
If  the  lesion  be  strictly  limited  to  the  speech  centre,  which 
it  very  rarely  is,  the  loss  of  mental  power  may  be  slight, 
but  whether  we  can  with  any  kind  of  aphasia  have  m-ental 
completeness  according  to  the  previous  standard  of  perfect 
health  of  the  individual  is  another  matter.  I  do  not  believe 
we  can  have  such  completeness  if  we  could  apply  proper  tests. 
I  have  never  seen  a  case  where  it  existed. 

Here  is  a  case  of  ixiralytic  insanity,  very  common  indeed, 
'where  extreme  bodily  helplessness  coexisted  loith  such  mental 
symptoms  as  made  the  patient's  preseiice  almost  intolerable  in  a 
private  house,  and  even  to  the  neighbours  who  lived  near. 

G.  Q.,  set.  64.  JIad  an  attack  of  apoplexy  with  left  hemi- 
plegia four  months  before  it  was  necessary  to  send  her  to  the 
Asylum.  Her  mother  died  of  apoplexy  at  the  age  of  84. 
There  was  no  other  neurotic  heredity  discoverable.  During 
the  first  month  after  the  apoplexy  she  was  stupid  and  half 
comatose.  Then  she  began  to  have  hallucinations  of  sight, 
and  to  be  fanciful,  irritable,  and  very  unreasonable,  to  sleep 
badly,  and  to  have  a  morbid  craving  for  food  with  no  sense  of 
satiety.  The  mental  symptoms  got  gradually  worse,  while 
the  hemiplegia  remained  complete.  She  became  subject  to 
periodic  fits  of  depression,  lasting  whole  days  and  nights, 
during  which  she  would  cry  and  scream  loudly  without 
intermission  in  a  peculiar  baby-like  voice  that  penetrated 
through  the  house  and  into  the  street,  and  was  most  annoying 
to  the  neighbours,  especially  at  night.  There  was  no  reason- 
ing with  nor  soothing  her.  It  was  evident  that  she  had  a 
sense  of  extreme  organic  discomfort,  and  that  she  probably 
had  pain.  Her  delusions  all  took  their  origin  from  her 
sensations.  She  affirmed  that  her  left  leg  and  arm  did  not 
belong  to  her,  and  would  order  that  they  should  be  taken 
away.  She  affirmed  her  food  was  poisoned,  and  she  said  the 
people  near  her  were  going  to  kill  her.     She  could  not  attend 


424  PAEALYTIC   INSANITY. 

to  the  calls  of  nature,  and  "wlien  moved  to  be  dressed  and 
washed  screamed  at  the  pitch  of  her  voice.  She  had  no 
memory  at  all  for  recent  events,  but  lived  in  the  past.  She 
was  very  emotional,  crying  nearly  every  time  she  was  spoken 
to,  but  her  appearances  of  emotion,  like  the  rest  of  her 
mental  life,  were  merely  automatic.  She  showed  no  real 
affection  for  her  family.  She  constantly  threatened  suicide. 
She  mistook  the  identity  of  those  about  her,  calling  strangers 
by  the  names  of  old  friends.  With  the  hand  she  could 
move  she  would  try  to  tear  and  destroy  and  break  things. 
After  about  three  months  of  this  state  she  had  to  be  sent 
to  the  Asylum,  chiefly  on  account  of  the  noise  she  made. 

She  was  fed  and  nursed  and  cared  for,  placed  on  a  water- 
bed,  and  kept  warm,  and  placed  in  a  room  where  her  noise 
did  not  disturb  others.  Sedatives  and  soporifics,  such  as  the 
bromides  and  chloral,  were  tried  in  moderate  doses.  They 
usually  did  not  act  in  producing  quiet  or  sleep  till  twelve 
hours  after  they  were  given.  This  is  not  uncommon  in 
maniacal  conditions.  An  old  night  attendant  I  once  had 
pointed  it  out  first  to  me.  He  divided  his  noisy  people  into 
two  classes — those  in  whom  the  night  draughts  produced 
sleep  the  night  they  were  given,  and  those  in  Avhom  they  pro- 
duced sleep  only  on  the  following  night.  The  advanced  and 
advancing  brain  disease  being  destructive  and  irritative  in  its 
character,  evidently  involving  the  convolutions  to  a  serious 
extent,  seemed  capable  of  no  alleviation.  She  steadily  got 
weaker,  and  died  in  about  four  months  from  the  beginning 
of  the  attack.  No  post-mortem  examination  was  permitted. 
The  case,  looked  at  from  the  point  of  view  of  mental 
symptoms,  was  one  of  melancholia  of  the  excited  variety  ; 
but  the  whole  of  the  mental  symptoms  were  so  secondary, 
in  a  clinical  point  of  view,  to  the  attack  of  apoplexy  and 
hemiplegia,  that  it  is  evident  the  appropriate  name  for  such  a 
case  is  that  of  paralytic  insanity.  The  irregular  periodicity  in- 
the  symptoms,  and  the  days  of  quiet  she  had,  seemed  to  me 
— and  this  is  markedly  the  case  in  many  senile  cases  too — to 


PARALYTIC   INSANITY.  425 

be  merely  tlie  stupor  and  inaction  of  a  spent  organ,  that 
tlirojagh  sheer  exhaustion  could  no  longer  evolve  energy  till 
an  accumulation  of  energy  again  took  place. 

The  folloioing  is  a  good  example  of  insanity  from  an  advanc- 
ing paralysis,  notlwmiplegic  at  fb'st,  caused  hy  progressive  brain 
destruction : — 

G.  E.,  set.  57.  Habits  intemperate.  !N"o  admitted  heredity 
to  the  neuroses.  Four  years  before  admission  to  the  Asylum 
he  had  some  sort  of  attack  that  was  described  as  "bilious," 
becoming  almost  blind  after  it.  He  then  became  subject  to 
severe  headaches.  About  fifteen  months  before  admission  he 
had  a  paralytic  shock,  affecting  both  sides  equally,  and  since 
then  his  mental  power  has  gradually  become  impaired.  At 
times  he  was  noisy  and  unruly  in  a  stupid  purposeless  fashion, 
thinking  that  some  one  was  coming  to  hurt  him.  When  he 
could  not  find  his  razor  one  day  he  set  fire  to  his  beard.  He 
would  attempt  to  leave  the  house  with  nothing  but  his  night- 
shirt on.  He  slept  badly,  and  was  restless,  and  often  noisy 
at  night.  He  used  to  repeat  the  former  acts  of  his  life  in 
an  automatic  absurd  way,  e.g.,  one  day  was  found  fishing  in 
liis  grate  with  a  bit  of  string  tied  to  a  stick.  His  memory 
especially  failed. 

When,  on  account  of  the  excitement,  noise,  and  difficulty 
of  management  at  home,  he  was  sent  to  the  Asylum,  he  was 
not  apparently  exalted  or  depressed  or  excited,  but  he  was 
much  enfeebled  in  mind,  his  speech  and  behaviour  being 
childish  and  his  memory  almost  gone.  He  could  not  tell  the 
day  of  the  week,  or  his  age,  or  the  number  of  his  children. 
He  expressed  no  delusions.  His  power  of  attention  was 
lessened.  He  evinced  no  great  surprise  or  curiosity  at  coming 
to  the  Asylum.  His  face  was  expressionless  and  flabby,  his 
gait  dragging  and  weak,  and  his  grasp  feeble.  His  articula- 
tion was  characteristic  of  such  cases,  being  thick  and  slurred 
but  not  tremulous.  It  was  simply  a  muscular  inability  to 
perform  the  fine  co-ordinations  of  speech.  The  tongue  was 
furred,   flabby,  and  tremulous  on  its  surface.     The  bowels 


426  PAKALYTIC   INSANITY, 

were  constipated;  heart  enlarged,  and  sounds  impure.  The 
sensibility  and  reflex  action  were  normal.  The  urine  was 
slightly  albuminous.     Temperature,  98° ;  pulse,  84. 

After  coming  to  the  Asylum  there  was  a  steady  downward 
course  in  mind  and  body.  At  night  he  was  often  noisy  and 
very  restless,  and  he  needed  to  have  his  bed-clothes  put  on 
and  be  attended  to  by  the  night  attendant  constantly.  "Was 
placed  in  our  infirmary  ward,  and  needed  much  attention  by 
day  and  night.  In  four  months  he  was  confined  to  bed,  and 
almost  entirely  paralysed,  but  still  noisy.  Then  he  got  into  a 
condition  of  semi-stupor,  and  in  eight  months  after  admission 
had  an  attack  of  apoplexy  with  left  hemiplegia  and  coma, 
and  died  in  twenty-four  hours  thereafter.  The  whole  disease 
lasted  four  years,  during  the  last  two  of  which  he  was  par- 
tially paralysed  and  affected  in  mind,  and  for  the  last  eight 
months  he  needed  asylum  treatment. 

The  folloioing  is  an  example  of  the  hind  of  recovery  that 
sometimes  tahes  place  in  paralytic  insanity : — 

G.  S.,  set.  62,  a  steady  temperate  man.  His  sister  was  a 
patient  in  the  Asylum  once.  Two  years  before  admission  he 
had  had  two  shocks  of  paralysis  on  the  left  side.  Since  then 
he  has  got  more  and  more  "nervous,"  and  at  times  noisy  and 
violent.  For  six  weeks  before  admission  he  had  been  dis- 
tinctly insane.  He  was  poor,  and  poorly  attended  to  at  home. 
On  admission  he  was  childish,  facile,  suspicious,  and  talkative. 
He  thinks  the  house  is  coming  down  on  him,  that  a  surgical 
operation  was  performed  on  him  yesterday,  and  that  people 
are  watching  him  to  do  him  harm,  and  many  other  changing 
fancies.  He  could  walk,  but  dragged  shghtly  the  left  leg. 
He  had  a  paralytic  thick  articulation.  His  heart  was 
diseased.  He  steadily  improved  under  a  good  diet,  regulated 
exercise  and  work,  and  general  supervision,  till  in  three 
months  he  left  the  Asylum  quite  sane,  and  able  to  earn  his 
own  livelihood,  though  not  strong-minded.  He  worked  as  a 
g'ardener  for  two  years,  and  then  was  sent  back  to  the  Asylum 
with  much    the   same   symptoms   as   at    first.     The   mental 


PARALYTIC   INSANITY.  42? 

symptoms  and  the  hemiplegia  again  disappeared  almost 
entirely,  and  in  seven  months  he  was  able  to  leave  the  Asylum. 
Though  not  able  to  work  much,  he  stayed  quietly  at  home 
with  his  son  while  he  lived. 

Brain  Tumours. — Among  the  causes  of  paralysis  and  para- 
lytic insanity,  other  than  apoplexies  and  ramoUissements, 
the  most  interesting  in  relation  to  the  mental  symptoms  they 
produce  are  brain  tumours.  Such  tumours  being  various 
in  kind,  position,  and  mode  of  growth,  those  conditions  all 
affect  the  symptoms  bodily  and  mental.  Some  tumours 
grow  slowly,  and  their  effects  can  be  traced  to  intracranial 
pressure  alone.  In  many  such  cases  no  symptoms  have  been 
present  during  life  at  all,  or  no  symptoms  that  could  lead 
to  a  correct  diagnosis.  Other  tumours  cause  violent  irritation, 
direct  and  reflex,  in  the  brain  tissues  near  and  distant. 
Others  cause  destructive  lesions,  and  especially  ramoUissements 
in  the  brain  tissue  near  them.  Others  set  up  slow  progressive 
changes  both  in  near  and  distant  parts  of  the  brain  and  the 
organs  of  special  sense.  Intense  cephalalgia  is  undoubtedly 
the  most  common  sensory  symptom.  There  are  no  headaches 
like  those  caused  by  tumours  of  the  brain.  They  sometimes 
stupefy  and  "drive  the  patient  mad."  Next  to  those,  optic 
neuritis  and  blindness  are  the  most  common  symptoms. 
The  motor  signs  are  paresis  and  paralysis  local  and  general, 
convulsions  local  and  general,  and  cougestive  attacks, — in 
those,  as  in  other  respects,  mentally  and  bodily,  imitating 
general  paralysis.  The  mental  symptoms  most  common  in 
cases  with  brain  tumour  are,  first,  irritability  and  loss  of  self- 
control,  and  "change  of  disposition,"  then  depression,  with 
or  without  excitement,  then  confusion,  loss  of  memory, 
muttering  to  self,  loss  of  interest  in  all  things,  perhaps 
delirious  attacks,  then  drowsy  half-consciousness,  ending  in 
coma  and  death.  Such  cases  may  die  in  a  month,  or  may 
run  on  to  twenty  years  from  the  beginning  of  the  symptoms. 
Different  authors  have  had  extraordinarily  different  ex- 
periences as  to  the  frequency  of  brain  tumours,  from  2  per 


428  PAEALYTIC   INSANITY. 

1000  up  to  28  per  1000  deaths  among  the  insane,  which 
latter  has  been  my  own  experience. 

The  following  is  an  interesting  and  venj  typical  case  ^  of  in- 
sanity from  tumour,  ivhich  illustrates  nearly  all  the  common 
mental  and  bodily  symptoms  of  that  disease : — 

G.  T.,  set.  38.  First  attack  of  insanity;  no  hereditary 
predisposition  so  far  as  can  be  ascertained;  was  intemperate 
in  his  habits,  which  is  given  as  the  predisposing  cause  of  his 
insanity,  the  exciting  cause  being  evidently  organic  disease 
of  brain;  has  shown  symptoms  of  insanity  for  four  years. 
His  first  mental  symptoms  seem  to  have  consisted  in  a  change 
of  temper,  great  irritabihty,  and  an  altered  affection  for  his 
wife  and  family.  His  first  bodily  symptoms  were  intense 
cephalalgia  and  a  gradually  increasing  blindness,  this  last 
preceding  by  some  time  the  mental  ahenation.  He  has  been 
getting  much  worse  mentally  of  late  —  being  excessively 
irritable,  violent  to  his  wife  and  daughters,  very  abusive  and 
foul  in  his  language,  and  then  would  accuse  his  wife  of  all 
the  violence.  He  still  drank  hard  when  he  could  get  whisky, 
and  all  his  mental  symptoms  were  very  much  worse  after 
drinking.  He  professed  to  be  sorry  for  his  violence  and  bad 
temper  afterwards.  The  bhndness  became  complete,  and 
he  also  became  slightly  deaf  shortly  before  his  admission. 
During  the  twelve  months  before  admission  he  had  several 
"epUeptic"  attacks.  He  wished  to  go  to  the  Asylum,  and 
walked  there  with  a  friend. 

On  admission  he  showed  slight  signs  of  excitement  and 
confusion  of  mind,  but  his  memory  was  good.  He  was  quite 
coherent,  and,  on  the  whole,  sharp  and  intelligent.  Could 
answer  questions  correctly,  and  had  no  delusions.  He  was 
a  heavy -looking  man,  Avith  the  bhnd  expression  of  face,  his 
features  combining  the  expression  of  an  advanced  general 
paralytic  and  a  man  who  is  drunk.     His  gait  was  aflected  like 

1  For  this,  along  with  other  cases  of  mine,  aud  more  full  observations 
oil  the  mental  accompaniments  of  brain  tumours,  see  Journal  of  Mental 
Science,  July  1872. 


PARALYTIC   INSANITY.  429 

that  of  a  tipsy  man.  His  speech  was  thick  and  rather  in- 
distinct. He  was  quite  blind,  and  was  deaf  in  his  right  ear. 
He  said  he  had  at  times  cramp  -in  his  legs.  Reflex  action  in 
legs  normal.  Eight  pupil  more  dilated  than  left,  and  both 
nearly  insensible  to  light.  Lungs  and  heart  normal.  Appetite 
good ;  tongue  very  white ;  bowels  costive.  Temperature, 
97-8° ;  pulse,  72,  good. 

He  remained  in  the  state  described  for  the  first  fortnight, 
except  that  on  the  very  sHghtest  provocation  he  became  wild 
with  passion, — completely  losing  control  over  himself,  and 
capable  of  doing  any  violence  to  those  about  him.  In  a  fort- 
night he  had  a  severe  epileptiform  fit,  and  was  quite  uncon- 
scious after  it,  but  he  was  as  usual  next  morning.  He  had 
such  attacks  frequently  ever  afterwards.  For  the  first  six 
months  there  was  little  change  in  him.  After  that  he  got 
more  obtuse  in  mind,  weaker  and  more  paralysed  in  his  legs, 
his  articulation  thicker  and  more  indistinct,  his  pharynx  more 
insensible  and  paralysed,  so  that  he  would  have  choked  him- 
self on  any  soHd  food.  In  nine  months  his  legs  were  quite 
paralysed,  and  his  conjunctivas  became  at  first  injected  and 
then  ulcerated,  with  ulcers  of  the  cornea.  During  the  whole 
time  he  suffered  from  his  disease  an  excessive  irritabihty  with 
violent  paroxyms  of  passion,  often  coming  on  without  any 
.cause,  were  his  chief  mental  characteristics.  Towards  the 
end  of  his  Hfe  a  clouding  of  his  faculties  took  place,  he  slept 
much,  and  immediately  before  death  he  was  semi-comatose. 
Reflex  action  in  his  legs  continued  very  acute  to  the  last.  He 
died  in  ten  months  after  his  admission,  and  about  five  years 
from  the 'beginning  of  his  disease. 

At  the  post-mortem  examination  the  following  appearances 
were  found : — 

Head. — Calvarium  hard  and  heavy,  but  not  very  thick. 
When  it  was  removed  a  very  curious  appearance  was  pre- 
sented. Over  the  surface  of  the  dura  mater  there  were  a 
great  many  Httle  cauliflower  -  hke  excrescences  scattered 
irregularly,  being  most  numerous  near  the  middle  Hne,  and 


430  PARALYTIC   INSANITY. 

tlie  largest  in  the  locality  of  the  Pacchionian .  bodies.  The 
base  of  each  was  surrounded  by  a  bulging  of  the  dura  mater, 
and  where  attached  to  this  each  was  quite  small,  forming  a 
short  pedicle.  They  varied  in  size  from  a  pea  to  a  bean ; 
they  looked  like  little  projections  of  brain  that  had  been 
made  to  squirt  out  through  small  holes  in  the  dura  mater  by 
slow  steady  pressure  from  within — little  hernise  of  the  brain. 
Each  had  a  very  thin  fibrous  covering  continuous  with  the 
dura  mater.  In  colour  they  resembled  a  mixture  of  grey  and 
white  substance ;  in  consistence  they  seemed  to  be  nearly  that 
of  ordinary  brain  convolution.  Each  had  a  clearly  cut  bed 
absorbed  out  of  the  bony  skull-cap,  only  leaving  a  transparent 
plate  of  bone.  There  was  a  large  one  over  the  right  orbital 
plate,  the  size  of  a  bean,  causing  complete  absorption  of  the 
bone,  so  that  it  projected  into  the  fat  behind  the  eye.  On 
attempting  to  raise  the  dura  mater,  it  was  found  that  this 
could  not  be  done  without  tearing  the  connection  of  these 
hernipe  with  the  convolutions.  At  the  narrowest  part  of  the 
neck  of  each,  as  it  passed  through  the  dura  mater,  evidently 
through  the  gradual  enlargement  of  a  vascular  opening,  it 
consisted  of  both  white  and  grey  matter,  so  that  when  torn 
off  there  was  a  small  white  spot  Hke  a  pin's  head  in  the  con- 
volution from  which  it  sprung.  On  section  it  was  seen  that 
this  white  substance  passed  through  the  grey  matter  of  the 
convolution  like  a  stalk,  and  was  continuous  with  the  ordinary 
white  brain  substance ;  and  outside  of  the  dura  mater  it  ex- 
tended into  each  hernia,  swelling  out  and  forming  its  centre, 
with  a  thin  covering  of  grey  substance.  By  gentle  pressure 
from  without  a  considerable  part  of  some  of  the  excrescences 
could  be  pressed  back ;  the  hernia  could,  as  it  were,  be  par- 
tially reduced,  but  this  broke  up  to  a  greater  extent  what  was 
evidently  slightly  softened  brain  substance  already. 

When  the  brain  was  lifted  up  a  large  tumour  was  found 
attached  to  the  right  side  of  the  cerebellum  and  along  part  of 
the  right  crus  cerebri,  pressing  on,  and  causing  partial  absorp- 
tion of  that  part  of  the  pons  Varolii  and  cerebellum.     It  was 


PARALYTIC   INSANITY.  431 

firmly  attached  to  the  fibrous  portion  of  the  temporal  bone, 
causing  absorption  of  the  bone,  and  entering  into  and  disorgan- 
ising the  internal  ear  of  that  side.  It  pressed  on  the  lower 
portion  of  the  middle  lobe  of  the  cerebrum,  causing  complete 
ramollissement  there,  so  that  the  fluid  in  the  ventricle  ran  out 
at  that  part.  The  tumour  was  hard  and  fibrous  in  some 
parts,  soft  and  cystic  in  others,  grey  in  colour,  and  somewhat 
irregular,  in  outline,  being  altogether  about  as  large  as  a  hen's 
egg. 

The  ventricles  were  much  enlarged,  and  contained  much 
fluid.  On  section  there  were  spots  of  ramollissement  over 
right  orbit,  at  base  of  middle  lobe  of  right  side,  and  in  corpus 
striatum  of  right  side,  the  white  substance  being  generally 
doughy.     Optic  nerves  and  tracts  grey  and  fibrous. 

Microscopic  Examination. — On  a  microscopic  examination 
of  the  brain  substance  in  the  fresh  state,  the  covering  of  each 
excrescence  was'  found  to  consist  of  fibrous  tissue,  being 
thinned _  dura  mater.  The.  inside  consisted  of  masses  of 
granules,  and  in  some  places  there  was  a  striated  appearance, 
being  the  remains  of  white  nerve  fibres.  The  arteries  were 
coated  in  most  places  with  granular  matter.  On  examination 
of  the  pedicles  of  the  excrescences,  the  granular  cells  were  not 
so  numerous,  and  the  white  fibres  were  perfectly  normal. 
At  the  surface  of  the  brain  the  appearance  was  that  of 
healthy  white  brain  substance.  Altogether  the  morbid 
appearances  were  more  marked  at  the  outside  of  each  hernia. 
On  examining  sections  of  convolutions,  hardened  in  chromic 
acid,  and  cut  and  prepared  by  Stirling's  method,  it  was  found 
that  the  blood-vessels  were  very  much  enlarged  and  tortuous, 
and  surrounded  by  granular  matter  and  a  great  number  of 
round  vacant  spaces  in  each  section.  Probably  these  had 
contained  some  morbid  product,  such  as  masses  of  granular 
matter,  which  had  fallen  out,  or  been  dissolved  by  the  tur- 
pentine and  spirit  in  the  process  of  preparation.  I  could 
scarcely  have  believed,  had  I  not  seen  this  case,  that  convolu- 
tional  brain  tissue,  grey  or  white,  could  have  been  pressed  out 


432  PAKALYTIC   INSANITY. 

through  holes  in  the  dura  mater  and  yet  have  retained  any 
normal  structure  at  all. 

Statistics  of  Paralytic,  Insanity. — In  the  nine  years,  1874- 
82,  we  have  had,  out  of  our  3145  admissions  to  the  Eoyal 
Asylum,  Edinburgh,  91  cases  diagnosed  as  paralytic  insanity. 
That  is  nearly  3  per  cent.  Of  those  91  cases,  17,  or  almost 
19  per  cent.,  recovered  mentally.  This  was  one  of  the  results 
of  statistical  inquiry  into  special  forms  of  insanity  that  sur- 
prised me.  Had  I  been  asked  before,  I  should  have  said  that 
it  was  quite  a  rare  thing  for  a  case  of  paralytic  insanity  to 
recover.  But  this  shows  that  when  a  gross  lesion  of  the  brain 
first  occurs,  it  often  sets  up  a  convolutional  storm  of  mania  or 
melancholia,  which  is  temporary  and  curable.  The  immediate 
mental  effect  is  of  the  nature  of  a  reflex  irritation,  with  tem- 
porary vascular  congestion,  which  subsides  like  any  other 
maniacal  or  melanchohc  attack.  Ten  cases  were  discharged 
more  or  less  improved,  in  addition  to  the  seventeen  recoveries. 
Forty-six  of  the  patients  have  died  up  to  this  time,  in  thirty- 
six  of  whom  post-mortevi  examinations  were  performed. 

Pathology  of  Paralytic  Insanity. — Looking  at  the  pathology 
of  paralytic  insanity,  as  disclosed  in  the  records  of  the  patho- 
logical appearances  found  in  those  tliirty-six  cases,  one  sees 
that  ordinary  brain  disintegrations  ("white  and  yellow 
softenings  ")  from  emboHsm  and  thrombosis  stand  as  the  most 
frequent  lesion.  These  "  softenings  "  existed  in  83  per  cent, 
of  the  cases.  Their  most  frequent  original  seat  was  in  the 
basal  gangHa,  but  in  most  of  the  cases  the  disintegration  had 
extended  into  the  white  substance  round  those  gangha  more 
or  less.  In  only  about  20  per  cent,  of  the  whole  number  was 
there  manifest  disintegration  of  the  convolutions.  In  four  of 
the  patients  the  lesion  was  confined  to  the  convolutions, — was, 
in  fact,  a  true  disease  of  the  convolutions  alone.  These  had 
been  epileptiform.  In  five  cases  only  were  there  adhesions  of 
the  pia  mater  to  the  convolutions,  and  in  two  of  these  the 
whole  pathological  appearances  so  resembled  those  of  general 
paralysis  that  I  think  they  had  been  instances  of  that  disease, 


PARALYTIC  INSANITY.  433 

complicated  by  ordinary  softenings  in  tlie  basal  ganglia. 
There  was  very  marked  atropliy,  with  or  without  softenings 
of  the  convolutions  in  twelve  cases,  or  one-third  of  the  whole 
number.  Through  atrophy,  or  adhesion  of  the  pia  mater,  or 
disintegration,  or  the  pressure  of  tumours,  the  convolutions 
were  manifestly  diseased  in  twenty-seven  of  the  thirty-six 
cases,  or  75  per  cent.  This  gives  so  far  a  definite  pathology 
to  paralytic  insanity,  by  showing  that  it  is  not  merely  through 
lesions  of  the  basal  gangha  and  their  reflex  convolutional  dis- 
turbances that  it  occurs,  but  through  appreciable  disease  of 
the  convolutions  themselves,  in  three-fourths  of  the  patients 
that  die.  Microscopic  examination  shows  that  scavenger  cells 
abound  in  the  cortex  in  most  cases  near  the  local  softenings, 
and  degenerations  and  atrophies  of  the  lymphatic  structures 
are  very  common  indeed. 

The  frequency  of  tumours  or  new  growths  was  surprising. 
They  were  found  in  seven  of  the  thirty-six  cases.  In  most 
of  them  there  was  manifest  secondary  convolutional  lesion, 
through  pressure  or  irritation,  in  addition  to  the  tumours. 
In  one  case  a  spiculum  of  bone  projected  into  the  pons  from 
the  base  of  the  calvarium,  setting  up  thickening  and  inflam- 
matory action.  The  atrophy  in  two  cases  was  of  that  kind 
that  affected  chiefly  the  white  substance  in  the  centre  of  one 
hemisphere,  leaving  the  grey  substance  of  the  convolutions 
like  a  crust  round  a  hollow  space  (like  the  case  figured  in 
Plate  YII.).  There  were  recent  haemorrhages  in  only  three 
of  the  cases ;  and  there  were  purulent  deposits  in  one. 

It  may  be  concluded,  therefore,  that  gross  brain  lesions, 
wherever  situated,  tend  to  cause  mental  disease  in  two  Avays 
— first,  by  reflex  or  other  irritation,  or  excitation  of  morbid 
convolutional  action  ;  and,  secondly,  by  actual  destruction, 
primary  or  secondary,  of  convolutional  structure. 


2  E 


LECTUEE  XL 
EPILEPTIC  INSAlflTY. 

Very  important ;  epilepsy  may  coexist  with  perfect  sanity,  but  it  tends 
always  to  eufeeblement  of  mind — Eifects  of  epilepsy  on  development 
of  brain  in  childhood  ;  stunting  ;  enfeebling — the  insanity  in  rela- 
tion to  the  Fits  occurs  ;  1,  After;  2.  Before;  3,  Instead  of  (Masked 
Epilepsy) ;  4.  Chronic  Dementia  from  continued  epilepsy  ;  5.  Epi- 
lepsy ceases  and  mania  takes  its  place  ;  6.  Occurs  in  rare  cases  in  the 
course  of  chronic  insanity — Typical  epileptic  insanity  ;  irritability  ; 
impulsiveness  ;  want  of  inhibitory  power  ;  tendency  to  violence  ; 
hallucinations  ;  homicidal  impulses  ;  perverted  religious  emotion- 
alism— Prevalence  of  epilepsy  and  epileptic  insanity  in  different 
parts  of  the  country,  and  in  the  two  sexes  ;  4  per  cent,  here  ;  20  per 
cent,  in  Cheshire  ;  less  common  in  women — Prognosis  bad  ;  tends 
to  dementia — Pathology  :  Treatment :  Precautions  against  violence  ; 
an  asylum  diet  ;  the  bromides  ;  counter-irritation. 

Whether  we  hold  epilepsy  to  comprise  every  raotor  spasm, 
even  the  slightest,  or  restrict  it  to  the  periodic  recurrence  of 
general  convulsions  begun  and  accompanied  by  unconscious- 
ness, it  may  exist  without  insanity.  But,  on  the  other  hand, 
in  a  very  considerable  proportion  of  cases,  epilepsy  has  as  its 
accompaniment  mental  disturbances,  amounting  often  to  in- 
sanity. And  a  very  important  form  of  insanity  it  is.  Long 
before  Dr  Skae  classified  mental  diseases  clinically,  epileptic 
insanity  was  recognised  and  named.  Erom  the  earHest  times 
its  mentah  accompaniments  have  increased  the  mystery  and 
terror  of  epilepsy.  When,  added  to  the  contortions  and  un- 
consciousness of  that  disease  during  a  fit,  there  were  afterwards 
developed  strange  hallucinations,  terrible  acts  of  impulsive 
violence,  and  striking  religious  delusions,  we  cannot  Avonder 
that  a  supernatural  cause  was  almost  universally  believed  in 


EPILEPTIC  INSANITY.  435 

of  old.  No  demon  could  by  any  possibility  produce  more 
fearful  effects  by  entering  into  a  man  than  I  have  often  seen 
result  from  epilepsy. 

The  first  great  fact  to  be  kept  in  mind,  in  regard  to  epilepsy 
in  its  mental  relations,  is  that  the  frequent  recurrence  of 
epileptic  fits  for  many  years  tends  in  some. degree  to  impair 
the  mental  faculties,  to  dim  the  reasoning  power,  to  twist  or 
take  the  fine  edge  off  the  feelings,  emotions,  and  sensibilities, 
to  affect  the  memory,  to  lessen  the  self-control,  and  to  change 
the  "  character,"  even  where  there  is  no  actual  insanity.  If 
a  man  only  takes  a  few  fits  in  his  lifetime,  and  they  are  far 
between,  there  may  be  no  mental  accompaniment  whatever 
except  the  unconsciousness  at  the  time  and  the  transient  con- 
fusion after  each  fit.  And,  beyond  a  doubt,  the  occurrence  of 
such  rare  fits  is  compatible  with  great  mental  power.  Julius 
Caesar,  Mahomet,  and  Napoleon  are  said  to  have  had  such 
occasional  attacks  of  epilepsy. 

When  I  speak  of  epilepsy  causing  insanity  and  mental 
symptoms,  you  must  clearly  understand  that  the  whole  series 
of  symptoms,  bodily  and  mental,  may  in  some  cases  be  the 
combined  result  of  a  general  disturbance  of  function  or  of 
disease  in  the  brain,  neither  the  convulsions  being  the  primary 
disease,  nor  the  mania,  but  both  being  equally  effects  of  the 
same  cause.  It  is  usual  for  the  epileptic  insanity  not  to 
follow  at  once  the  first  appearance  of  the  fits.  Most 
commonly  years  elapse  before  it  comes  on.  No  doubt  the 
more  severe  and  the  more  frequent  the  fits,  the  greater  is  the 
risk  of  insanity,  but  certain  epileptics  suffer  merely  a  gradual 
mental  clouding  and  diminution  after  years  of  epilepsy,  while 
others  have  furious  mania  very  soon  after  the  first  fits  have 
appeared.  It  would  seem  as  if  certain  cases  of  epilepsy  from 
the  beginning  consisted  essentially  in  their  nature  quite  as 
much  of  a  mental  as  of  a  motor  instabihty  and  explosive- 
ness.  I  do  not  agree  with  Hughlings  Jackson  that,  in  cases 
of  petit  mat  and  slight  convulsions,  the  explosion,  not  finding 
vent  in  a  motor  form,  is  more  apt  to  extend  up  into  mental 


436  EPILEPTIC   insanity:. 

centres.  There  are  some  few  such  cases,  but  in  my  experience 
only  a  few.  The  theory  is  fascinating,  hut  there  is  danger 
in  making  too  close  an  analogy  between  a  mental  disturbance 
and  an  ordinary  motor  convulsion,  and  in  regarding  them  as 
virtually  the  same  thing,  the  one  being  an  "  explosion  "  in  a 
"mental  centre  "  and  the  other  in  a  motor  centre.  I  admit 
that  such  a  view  is  most  instructive  as  a  hypothesis  and  help 
in  making  definite  one's  ideas,  and  in  some  rare  cases  of 
epileptic  insanity  seems  to  fit  the  facts  exactly,  and  explain 
the  apparently  substitutionary  character  of  the  convulsion  and' 
the  psychosis.  But  in  a  very  large  number  of  cases  of  epileptic 
insanity  the  mental  symptoms  are  not  of  the  sudden  explosive 
character  at  all,  as  we  shall  see,  and  they  are  by  no  means 
always  attended  with  unconsciousness  or  false  consciousness, 
loss  of  memory,  and  want  of  power  of  attention.  The  theory 
of  explosion  assumes  that  you  have  a  morbid  energy  developed 
in  such  brains  which  when  not  inhibited  will  out  in  some  form, 
just  like,  gunpowder,  which,  if  you  obstruct  the  muzzle,  will 
blow  out  the  breach  of  your  gun. 

Relationshijp  of  Epilepsy  to  Mental  Symptoms. — Epileptic 
insanity,  and  by  this  I  mean  all  the  morbid  mental  effects 
associated  with  the  disease,  occurs  in  relation  to  the  fits  in 
six  chief  ways : — (1)  After  them.  This  is  on  the  whole  the 
most  common,  and  the  mental  symptoms  then  seen  are 
essentially  periodic  and  paroxysmal,  like  the  motor  convul- 
sions. They  follow  usually  within  twenty-four  hours  of  the 
fit  or  fits.  If  there  have  been  a  series  of  fits,  they  are  much 
more  apt  to  occur  than  after  one  only.  (2)  Before  the  fits. 
They  usually  show  themselves  a  day  or  two,  rarely  three  or 
four,  before  a  fit  is  coming  on.  And  in  some  such  cases,  when 
the  fit  occurs,  the  mental  irritabihty,  suspicions,  impulsiveness, 
or  confusion  usually  disappear  at  once,  their  place  being 
taken  by  stupidity,  or  in  some  cases  by  normal  mentahsation. 
This  is  undoubtedly  a  strange  fact,  but  is  abundantly  seen. 
Our  attendants  in  asylums  can  tell  in  this  way  when  a  fit  is 
coming  on  in  many  of  the  epileptics  under  their  care.     The 


EPILEPTIC   INSANITY.  437 

fit,  like  a  thunderstorm,  seems  to  clear  the  air.  .(3)  Mental 
disturbance  may  occur  instead  of  the  fits,  taking  their  place, 
apparently  coming  on  at  the  period  when  the  fits  might  have 
been  expected.  This  is  rare,  but  very  instructive.  It  is  the 
epilepsie  larvee,  or  masked  epilepsy,  of  the  French.  (4)  A 
slow,  steadily  progressing  loss  of  memory  and  change  of 
affection,  a  blunting  of  the  finer  feehngs,  and  a  permanent 
mental  obscuration  or  twisting,  those  being  often  the  very  first 
symptoms  present,  growing  more  intense  the  longer  the  patient 
lives  and  takes  the  fits.  This  is,  in  fact,  a  dementia  either 
from  brain  injury  by  the  fits  or  from  the  natural  advance 
through  prolongation  of  the  morbid  brain  state  that  caused 
the  epilepsy.  Most  epileptics  tend  to  become  demented  if 
they  live  long  enough.  The  arrest* of  mental  development, 
and  the  degeneration  towards  idiotic  conditions  seen  in  nearly 
all  cases  where  epilepsy  occurs  early  in  life,  come  under  this 
heading,  (5)  Some  forms  of  chronic  insanity  take  the  place 
of  the  fits,  which  cease  altogether.  I  have  seen  only  four  or 
five  cases  where  this  took  place,  and  they  all  occurred  at  the 
termination  of  the  reproductive  period  of  life,  (6)  Epilepsy 
may  begin  in  the  course  of  chronic  insanity  of  many  years' 
duration,  apparently  through  advance  of  disease  from  the 
mental  into  the  motor  centres  of  the  brain.  I  do  not  mean 
a  mere  sporadic  convulsion  or  series  of  convulsions,  in  the 
course  of  a  case  of  recent  or  chronic  insanity,  such  as  I  have 
described  in  that  form  of  melancholia  which  I  have  called 
convulsive,  or  as  in  the  case  of  prolonged  folie  circulaire, 
D.  B.,  p.  228,  or  like  those  cases  of  alcoholic  or  syphilitic 
insanity  in  which  convulsions  play  a  part.  I  refer  to  those 
cases  of  chronic  insanity,  usually  dements,  who  become 
epileptic,  beginning  to  take  regular  periodic  fits  after  being 
many  years  insane,  and  then  going  on  taking  them  regularly. 
I  have  seen  about  a  dozen  such  cases,  and  now  have  five  such 
under  my  care. 

It  will  be  observed  that  all  those  relationships  point  to  a 
close  connection  between  the  locus  in  quo  of  epilepsy  in  the 


438  EPILEPTIC  INSANITY. 

brain  and  the  seat  of  mental  disturbance.  The  fact  that  they 
are  related  to  each  other  in  such  various  ways  is  the  strongest 
proof  of  the  nearness  of  their  pathological  seat.  The  experi- 
mental demonstration  of  a  motor  function  in  the  convolutions 
seems  to  be  strongly  confirmed  by  all  the  clinical  facts 
of  epileptic  insanity.  Hereditarily,  ordinary  insanity  and 
epilepsy  are  more  closely  allied  than  any  other  two  of  the 
neuroses.  The  son  or  daughter  of  an  epileptic  is  just  as 
likely  to  be  weak-minded,  drunken,  or  insane  as  to  be 
epileptic;  and  certainly  epilepsy  occurs  frequently  in  the 
children  of  famiUes  with  a  strongly  insane  heredity. 

Mental  Symptoms. — The  actual  mental  symptoms  caused 
by,  or  associated  with,  epileptic  fits  vary  considerably,  as  we 
shall  see  from  the  cases  that  will  be  related;  but  there  is 
a  certain  type  of  psychosis  so  common  as  to  be  almost 
characteristic.  Two  words  express  its  most  marked  character- 
istics— irritabihty  and  impulsiveness.  I  suppose  one  may 
look  on  these  as  representing  an  abnormal  state  of  nutrition" 
and  energising  of  the  brain  convolutions,  and  a  dynamical 
instability,  whereby  there  is  a  morbid  energy  evolved  and 
a  want  of  inhibition  to  control  it.  The  epileptic  psychosis 
may  exist  in  every  degree,  from  the  merest  excess  of  irritable 
temper  up  to  the  most  dangerous  homicidal  impulses  and  acts. 
I  have  seen  epileptic  insanity  take  the  form  of  a  more  acute 
maniacal  condition  than  almost  any  other  insanity.  Before 
the  days  of  the  bromide  of  potassium,-  and  its  regular  use  in 
the  cases  of  most  epileptics  in  asylums,  no  patients  Avere  so 
troublesome  or  dangerous.  There  is  no  form  of  insanity  that, 
outside  asylums,  is  more  frequently  the  cause  of  murders, 
except,  perhaps,  the  alcohoHc.  Hence  its  medico-legal 
importance  to  medical  men  and  jurists.  It  depends  much 
on  the  strength  and  intelligence  of  the  medical  evidence 
whether  an  epileptic  murderer  is  hanged  or  sent  to  Broad- 
moor Criminal  Lunatic  Asylum.  If  a  man  has  been  subject  to 
regular  epileptic  fits,  and  commits  a  murder  in  an  impulsive  or 
motiveless  way,  then  I  think  the  presumption  would  be  very 


EPILEPTIC   INSANITY.  439 

strong  that  he  was  not  fully  responsible  for  his  actions.  ]^o 
prejudice  or  want  of  knowledge  on  the  part  of  judges  or  juries 
should  prevent  a  medical  man  from  giving  clear  evidence  on  this 
point.  A  murder  by  an  epileptic  should  usually  be.  looked 
on  as  being  as  much  a  symptom  of  his  disease  as  larceny  by 
a  general  paralytic.  Certainly  the  onus  prohandi  as  to  his 
responsibihty  should  rest  on  the  prosecution. 

A  certain  religious  emotionalism  of  a  strong  and  usually 
perverted  kind  is  often  present  in  epileptics,  as  pointed  out 
by  Dr  Howden.  "We  had  a  lad  (G.  W.)  in  whose  ante- 
bromide,  and  therefore  natural,  epileptic  clinical  history  it 
was  a  sure  prelude  to  a  fit,  or  series  of  fits,  that  he  took  his 
Bible,  read  it  continuously,  and  when  spoken  to  would 
answer  fiercely — "Don't  trouble  me,  I'm  a  good  man.  I'm 
a  servant  of  God."  The  day  after,  he  would  be  walking  up 
and  down,  striking  any  patient  or  any  one  else  who  ventured 

to   speak   to  him,  replying  maniacally — "You're   a   d d 

liar !  Don't  insult  me  !  "  if  one  remarked  to  him  it  was  a 
fine  day.  That  night  he  would  have  one  or  two  fits,  and 
would  be  stupid  and  much  inclined  to  masturbation.  Next 
day  he  would  keep  his  bed,  and  after  a  day  or  two  would  get 
up  and  go  about  as  usual.  The  bromide  treatment,  in  doses 
of  20  grains  three  times  a  day,  utterly  destroyed  the  typical 
psychosis  as  weU  as  diminished  the  number  of  fits  for  twelve 
years,  he  being  nearly  all  the  time  a  mild,  industrious,  slightly 
weak-minded  young  man,  who  did  what  he  was  told  and 
only  took  a  fit  every  six  months  instead  of  a  series  of  them 
every  month.  But  at  the  end  of  the  twelve  years  the  old 
irritability  returned,  and  he  died  in  the  thirteenth  year. 
Epileptics  rarely  Hve  long  lives. 

As  illustrating  epileptic  irritability  not  reaching  the  maniacal 
stage,  look  at  those  two  women,  G.  X.  and  G.  Y.  The  one, 
G.  X.,  rages  at  her  nurse,  calls  her  a  murderess,  affirms 
that  she  has  given  her  no  food  to-day — she  has  just  had  her 
dinner,  eating  half  of  it  and  throwing  the  remainder  at  the 
nurse — and  that  she  has  tried  to  poison  her  often.     JSTothing 


440  EPILEPTIC   INSANITY.  . 

you  can  say  to  lier  but  will  rouse  anger.  K"o  remark, 
however  mild,  but  will  excite  a  storm  of  scolding,  j^o 
soothing  influence  will  mollify  her  in  the  least  degree.  She 
tries  to  imitate  your  voice.  She  is  sarcastic,  abusive,  and 
threatening  by  turns,  as  I  demonstrate  the  failure  in  this  case 
of  the  psychological  experiment  of  a  soft  answer  beiag  able  to 
turn  away  wrath.  By  the  way,  that  psychological  aphorism  is 
more  applicable  in  dealing  with  the  insane  than  almost  any 
other  class  of  human  beings.  It  stands  me  in  good  stead 
many  times  every  day ;  and  if  I  could  only  practise  it 
always  myself,  and  get  my  attendants  to  practise  it,  we 
should  save  many  rows,  and  avoid  on  many  occasions  the  use 
of  physical  force.  But  I  am  bound  to  say  it  altogether  fails 
sometimes,  and  notably  in  this  patient  and  in  other  epileptics. 
But  just  try  the  opposite  tack,  and  contradict  her  and  tell  her 
sharply  that  she  is  an  unreasonable  woman,  who  is  talking 
nonsense  and  acting  Hke  a  fool.  How  this  aggravates  all  her 
symptoms !  She  shouts,  and  at  once  threatens  personal 
violence.  "  IS'ever  contradict  or  attempt  to  reason  with  an 
epileptic  Avhen  excited,"  is  an  axiom  in  asylums.  Now,  this 
woman  had  a  fit  two  days  ago,  and  by  to-morrow  her 
irritability  will  have  passed  off,  and  she  will  be  a  quiet,  civil, 
and  agreeable  woman. " 

The  next  patient,  G.  Y.,  is  in  much  the  same  general 
condition  of  morbid  irritability.  She  sings  a  psalm  tune  in  a 
noli  me  tangere  tone  of  voice.  When  I  ask  her  mildly  what 
tune  that  is,  she  denounces  me  as  a  hypocrite  and  a  scoundrel, 
says  I  am  of  the  seed  of  the  devil,  and  that  she  is  one  of 
God's  people  and  of  the  seed  of  Israel.  This  delusion  recurs 
Avhenever  she  has  fits.  She  describes  visions  she  has,  when 
she  sees  Jesus  Christ  and  the  prophets.  At  times  she  has 
the  hallucination  that  she  is  surrounded  by  flames,  and  sees 
eyes  like  fiery  balls  glaring  at  her.  She  is  almost  never 
amiable,  is  subject  to  morbid  suspicions  and  aversions  to 
certain  people.  Her  social  instincts  have  been  almost  up- 
rooted by  her  disease. 


EPILEPTIC   INSANITY.  441 

In  both  those  cases  the  bromide  has  been  tried,  and  failed 
to  do  good.  This  has  partly  resulted  from  the  fact  that  the 
trial  was  imperfect,  for  they  both  believed  it  was  poison  given 
to  do  them  harm,  resisting  and  refusing  it,  and  partly  because 
the  epilepsy  they  are  both  subject  to  is  nocturnal.  This  is 
never  so  subdued  by  the  bromides  as  the  fits  taken  by  day,  and 
the  epileptic  psychosis  associated  with  nocturnal  epilepsy  is 
also  less  amenable  to  the  good  effects  of  the  drug.  Epileptic 
insanity  is  not  nearly  so  common  among  women  as  men, 
whatever  may  be  the  case  with  uncompHcated  epilepsy  ;  and 
when  it  occurs  it  is  less  benefited  by  the  bromides  in  most 
cases.^ 

Next,  let  us  take  a  case  of  typical  epilepsy  and  typical 
epileptic  insanity  in  a  man,  a  patient  that  illustrates  a  great 
many  clinical  facts  of  an  instructive  hind  : — 

H.  A.  was  said  to  have  been  thrown  from  his  palanquin  in 
India  at  the  age  of  17,  and  to  have  alighted  on  the  left  side 
of  liis  head.  He  did  not  suffer  much  at  the  time,  and  had 
no  epileptic  fits  till  seven  years  afterwards,  when  home  on 
furlough.  Yet  on  this  slight  post-hoc  the  epilepsy  was  put 
down  to  the  fall  in  India.  Relatives  will  always  assign  some 
cause  for  such  a  disease.  There  have  been  neuroses  and 
mental  disease,  but  no  epilepsy,  in  the  family.  The  fits  began 
in  March  one  year,  and  were  numerous  and  severe.  They 
usually  came  on  about  every  month,  but  sometimes  every  day 
or  two.  In  September  following  he  had  a  severe  maniacal 
attack,  for  which  he  was  sent  to  the  Asylum.  It  was  accom- 
panied by  unconsciousness,  and  a  constant  rotating  motion 
from  left  to  right,  the  eyes  staring  in  a  fixed,  glassy  way. 
His  condition  was,  in  fact,  more  a  stupor  with  motor  restless- 
ness. This  is  not  an  uncommon  kind  of  epileptic  psychosis. 
This  lasted  for  ten  days,  and  he  then  got  well.  He  had  a 
pain  in  the  left  side  of  his  head,  especially  before  the  fits ; 
and  his  left  arm  in  the  fits,  especially  in  the  clonic  spasm, 

^  For  the  exact  statistics,  see  the  author's  paper  on  this  subject  iii  the 
Jouriial  of  Mental  Science  for  October  1868. 


442  EPILEPTIC   INSANITY. 

twitched  more  than  the  right.  It  was  thought  that  those 
things  pointed  to  a  depression  of  bone,  or  some  such  local 
irritation,  at  the  part  where  he  fell.  The  late  Mr  Syme 
trephined  the  hone  at  the  spot,  taking  out  a  circle  about  the 
size  of  a  halfpenny.  A  "  very  questionable  alteration  "  in 
the  bone  was  thought  to  be  detected.  "Xo  alteration  was 
detected  on  microscopic  examination."  In  a  week  he  had  a 
maniacal  attack,  without  having  any  fits,  during  which  he  was 
most  violent — shouting,  strugghng,  recognising  no  one.  To 
prevent  him  injuring  the  wound  he  was  kept  in  bed  by  a 
number  of  sheets  and  skeins  of  worsted.  This  lasted  for  a 
fortnight,  when  he  got  well  again.  For  three  months  he 
kept  well,  and  was  discharged  from  the  Asylum  "  reheved," 
having  no  fits  for  four  months  after  the  operation.  He  then 
became  depressed  in  mind  and  emotional,  weeping  much. 
This,  as  a  temporary  phase  of  epileptic  psychosis,  is  not 
uncommon.  He  then  had  several  fits,  which  were  followed 
^vithin  two  days  by  an  acute  attack  of  mania,  with  frenzied 
violence.  He  was  put  in  restraint  in  the  sheets  again,  as  his 
scalp  was  tender,  and  he  threw  himself  against  the  walls  of 
the  room.  As  he  got  out  of  the  unconscious  maniacal  state 
he  was  irritable,  unreasonable,  and  complained  of  everything. 
!N"othing  or  nobody  could  please  him.  This  was  the  very 
opposite  of  his  natural  disposition,  which  was  most  considerate 
and  gentlemanly.  In  four  months  after  this  he  had  a  recur- 
rence of  the  fits  and  a  maniacal  attack.  He  then  took  the 
fits  occasionally  during  the  next  six  months,  without  there 
being  any  mania.  But  he  was  Hable  to  sudden  short  attacks 
of  epileptic  psychosis,  during  which  he  would  suddenly  strike 
out  at  those  near  him,  or  his  expression  of  face  would  change 
and  become  furious,  wliile  he  would  stare  at  any  one  beside 
him,  and  shout  fiercely — "  'What  the  devil  do  you  mean,  sir  ? " 
This  state  would  occasionally  come  on  of  itself  without  any 
exciting  cause,  but  would  sometimes  be  set  up  by  contradic- 
tion, or  when  he  saw  anything  done  that  he  disapproved  of, 
I  remember  being  one  of  a  party  of  four  playing  whist,  he 


EPILEPTIC   INSANITY.  443 

being  one.  We  were  playing  quietly,  not  a  word  being  said, 
when  he  suddenly  let  go  his  cards,  stared  at  his  partner  with, 
his  eyes  "rolling  out  of  his  head,"  and,  with  a  damnatory 
exclamation,  sprang  at  his  throat  'over  the  table.  He  was 
seized,  held  gently  on  the  sofa  for  a  few  minutes,  came  to 
himself,  asked  what  had  been  up,  and  went  on  with  the  game. 
He  remembered  nothing  about  what  had  occurred.  This  was 
a  true  attack  of  "  mental  epilepsy."  He  then  began  to  take 
the  fits,  about  one  every  week,  nearly  always  during  the  day. 
He  was  subject  to  various  sensory  neuroses,  as  most  epileptics 
are,  such  as  sensations  of  pins  and  needles  in  his  limbs,  a 
feeling  as  if  there  were  twitchings  in  his  head  especially  after 
going  to  bed  and  before  going  to  sleep,  numbness  in  his  left 
thumb,  and  tic  in  his  right  eye  and  temple. 

AH  sorts  of  treatment  were  tried  for  the  disease — morphia 
by  mouth  and  subcutaneously,  sulphates  of  zinc  and  copper, 
severe  purgation,  counter-irritation,  colchicum,  and  alkalies, 
but,  while  he  seemed  to  be  a  little  better  for  each  drug,  he 
soon  became  as  bad  as  ever.  Occasionally  he  would  pass 
two  months  without  a  fit,  except  perhaps  a  few  attacks  of 
petit  mat.  In  1865  he  was  put  on  the  bromide  of  potassium, 
in  10-grain  doses  three  times  a  day.  In  a  month  he  said  he 
felt  much  better  in  health,  had  no  nervousness,  and  little 
of  the  twitching  feeling.  His  general  health  became  better. 
For  five  months  he  took  this,  and  had  five  fits  in  that  time, 
only  one  of  them  being  severe,  and  he  had  no  nianiacal 
excitement.  The  dose  was  then  doubled,  that  is,  he  took  20 
grains  thrice  a  day.  For  one  hundred  days  after  that  he 
had  only  two  attacks  of  jyetit  mal,  then  he  had-  a  slight  fit. 
He  kept  so  well  in  mind  that,  after  a  year  of  the  bromide 
treatment,  he  left  the  Asylum  on  probation,  being  charged  to 
go  on  with  the  medicine.  He  stayed  at  home  for  six  months, 
and  did  well.  Then  he  began  to  take  the  fits  rather  more 
frequently,  taking  about  two  or  three  in  the  month  of  a 
slighter  character.  He  then  came  back  to  the  Asylum  volun- 
tarily, not  being  maniacal.     The  fits  almost  always  came  on 


444  EPILEPTIC   INSANITY. 

just  after  waking,  or  during  sleep  about  5  a.m.,  thus  changing 
their  character  from  day  to  night  fits.  Bromide '  acne  use  to 
trouble  liim,  and  he  would  on  that  account  stop  the  medicine, 
but"  he  always  had  a  fit  within  three  days  after  this. 

For  the  next  two  years  he  continued  to  take  fits  about 
every  month  or  six  weeks,  but  was  never  maniacal,  and 
during  the  day  he  entered  into  the  amusements  of  the 
Asylum,  playing  billiards  and  cricket,  dancing,  &c.  Of  one 
tiling  he  never  could  be  made  to  realise  the  importance, 
and  that  was  the  risk  he  ran  in  dangerous  places  on 
account  of  a  fit  suddenly  coming  on,  in  this  being  like  most 
epileptics.  He  would  constantly  stand  near  the  fire,  or 
walk  near  steep  places.  When  at  a  picnic  at  the  Falls 
of  the  Clyde  once,  he  went  quite  near  one  of  them  to 
look  over.  "Wlien  warned  of  the  risk,  he  coolly  remarked 
that  life  would  not  be  worth  having  if  he  were  always 
thinking  of  the  risks  from  a  fit.  It  seemed  to  me  the  bromide 
treatment  not  only  lessened  the  irritability  of  temper  and  the 
number  of  maniacal  attacks,  but  that  in  tliis  case  it  prevented 
the  mental  degeneration  in  feelings  and  manners  that  long- 
continued  epilepsy  is  apt  to  cause. 

In  September  1872  he  took  a  fit  by  day  when  standing 
with  his  back  to  an  oj)en  fire,  fell  backwards,  and  burned 
himself  most  severely  in  the  gluteal  region,  causing  a  sore  of 
9  inches  in  diameter.  Fo-r  nine  months  after  this,  tvhile  the 
sore  was  discharging  much  jpus,  he  had  no  Jits,  though  talcing 
no  bromide.  This  I  have  seen  very  frequently  in  epilejptics. 
Then  liis  fits  began  again,  but  were  very  infrequent.  His 
lungs  then  began  to  be  afi'ected.  In  about  a  year  the  wound 
healed,  and  for  the  first  time  since  the  burn  he  had  a  mild 
maniacal  attack.  The  lung  disease  gradually  progressed, 
and  he  died  in  tAvo  years  and  a  half  after  the  burn.  He 
had  not  a  trace  of  mania,  and  very  few  fits,  for  the  last 
nine  months  of  his  life,  during  which  his  lungs  were  very 
far  gone. 

On  'post-mortem  examination,  the  dura  mater  was  found 


EPILEPTIC   INSANITY.  -445 

adherent  to  tlie  lower  surface  of  the  circular  hole  made  in 
tr,ep.hining  the  skull-cap,  and  was  adherent  below  to  the 
arachnoid  and  pia  mater.  There  were  no  spiculae  nor  thicken- 
ings of  the  ^bone  towards  the  brain  anywhere.  On  the  left 
side  of  the  spot  operated  on  the  pia  mater  was  adherent  to  a 
brain  convolution.  The  arachnoid  was  slightly  milky,  and 
there  was  considerable  vascularity  in  the  brain  substance, 
with  some  little  perivascular  atrophy.  Otherwise  the  brain 
was  normal,  and  the  medulla  was  not  congested,  though  the 
vessels  were  enlarged. 

The  condition  of  the  brain  did  not  confirm  the  idea  of  an 
injury  from  the  original  fall,  and  threw  no  light  on  the  cause 
of  the  epilepsy. 

Variety  of  Symptoms. — In  this  one  case  you  see  there 
existed  at  different  times,  and  under  different  circumstances, 
epileptic  irritability ;  epileptic  mania  with  and  without  con- 
sciousness, the  latter  at  times  being  wildly  dehrious  and  in  the 
highest  degree  dangerous  to  the  patient  and  those  near  him ; 
epileptic  impulsiveness  of  action  and  violence;  epileptic  stupor; 
epileptic  depression ;  epileptic  false  consciousness ;  epileptic 
automatism ;  the  characteristic  epileptic  want  of  realisation  of 
the  dangers  to  which  the  liability  to  take  the  fits  any  moment 
exposes  the  patients ;  epileptic  sensory  neuroses ;  the  tem- 
porary improvements  that  counter-irritation  and  new  modes 
of  treatment  are  apt  to  produce  in  epilepsy;  the  decided 
relief  of  many  of  the  symptoms  by  the  use  of  the  bromide  of 
potassium,  which  yet  did  not  cure,  and  acted  best  at  first ; 
the  cessation  of  the  fits  and  of  the  tendency  to  maniacal 
outbursts  when  serious  bodily  diseases  came  on;  lastly,  the 
present  unsatisfactory  pathology  of  the  disease  was  also 
illustrated. 

Epileptic  Insanity  and  Insane  Impulses. — Epileptic  insanity 
should  be  studied  along  with  the  symptomatological  class  of 
impulsive  insanity,  with  which  it  is  very  nearly  allied  in 
symptoms  and  heredity.  I  have  already  alluded  to  the  case 
of  E.  T.  (p.  340),  so  many  of  whose  children  died  of  convul- 


446  EPILEPTIC   INSANITY. 

sions,  and  whose  brother  is  an  epileptic  patient  in  the  Asylum. 
It  is  also  closely  allied  to  somnambulism.  Epileptic  insanity 
proper  is  accompanied  by,  and  complicated  with,  some  of  the 
most  extraordinary  and  irregular  mental  phenomena.  I  have 
a  man,  H.  B.,  who  at  times  has  hallucinations  of  smell, 
fancying  the  air  is  polluted  round  him  by  putrid  meat; 
another,  H.  C,  who  affirms  that  we  cause  itching  and  formi- 
cation of  his  skin,  he  scratching  himself  violently  after  fits 
sometimes.  I  have  known  a  "  fit  of  itching  "  come  on  in 
him  instead  of  an  epileptic  fit.  We  have  several  epileptics 
who  receive  messages  from  the  Deity  after  fits.  I  had  a 
woman,  H.  D.,  who,  before  and  after  a  fit,  and  while  she  is 
taking  it,  for  she  does  not  lose  her  consciousness,  imagines 
she  has  two  heads,  and  that  one  is  under  her  own  control  and 
the  other  under  the  control  of  an  enemy.  In  her  case  the  fits  are 
unilateral  at  first.  I  have  a  man,  H.  E.,  in  whom  an  aphasic 
attack  comes  on  and  lasts  for  periods  from  one  hour  to  three 
days,  instead  of  epilepsy,  he  being  meanwhile  rational,  cheer- 
ful, and  industrious,  and  writing  on  paper  anything  he  has  to 
say  or  ansAvers  to  questions.  I  had  at  the  Carlisle  Asylum  an 
epileptic  idiot  whose  muscles  seemed  to  be  in  constant  action 
when  he  was  awake.  He  was  never  quiet,  and  most  of  his 
actions  were  purposive  for  mischief.  He  was  the  pest  of  the 
ward  where  he  hved.  He  would  kick,  bite,  scratch,  and 
annoy  his  fellow-patients  on  all  occasions,  but  especially 
when  they  were  asleep  or  quiet.  No  imp  of  Satan  could 
have  been  more  ingeniously  tormenting. 

Suicidal  impulses  are  not  common  in  epileptic  insanity. 
When  present,  they  usually  result  from  hallucinations  of  hear- 
ing voices  telhng  the  patient  to  commit  the  act.  I  had  lately 
a  well-marked  case  of  this  sort,  H.  E.,  a  man  aged  39  when 
he  was  sent  to  the  Asylum,  who  had  been  subject  to  epilepsy 
for  several  years,  and  had  often  been  maniacal.  During  one 
of  his  attacks  he  had  bitten  olf  his  father's  nose,  under  the 
delusion  that  he  was  calling  him  bad  names.  When  well  he 
was  attached  to  him.     He  had  exposed  himself  to  some  of  the 


EPILEPTIC   INSANITY.  447 

strongest  causes  of  brain  disease,  for  he  had  drunk  hard — 
epileptics  very  often  do,  and  alcohol  always  makes  them  irri- 
table or  maniacal — had  contracted  syphilis,  and  exceeded  with 
women,  and,  when  a  soldier  in  India,  had  been  exposed  to 
the  sun  and  had  sunstroke.  When  admitted  he  was  very 
violent  and  homicidal.  He  heard  voices,  as  if  it  were  his 
fellow-patients  calling  him  foul  and  offensive  names,  such  as 
"thief,"  "scoundrel,"  "beggar,"  &c.  He  would  often  assault 
savagely  men  who  were  not  speaking  to  him  at  all.  He  took 
the  fits,  which  were  of  the  ordinary  character,  about  every 
fortnight.  The  hallucinations  and  homicidal  tendency  were 
usually  worst  before  the  fits,  but  he  was  always  irritable, 
sullen,  and  unsocial,  and  had  a  very  strong  and  uncontrollable 
craving  for  drink  and  tobacco.  He  was  put  on  the  bromide 
of  potassium  in  25-grain  doses  three  times  a  day.  At  first 
it  seemed  to  have  no  effect,  but  after  about  six  months  he 
became  mentally  changed  for  the  better.  He  got  chatty, 
amiable,  and  industrious.  He  had  occasional  outbursts  of 
suUenness  and  irritability,  but  seldom  was  violent.  He  had 
the  hallucinations  of  hearing  very  often,  but  he  said  he 
disregarded  them,  and  latterly  said  he  had  got  himself  to 
believe  by  reasoning  that  they  were  "voices"  only,  and  not 
the  words  of  actual  men.  If  he  took  liquor  he  was  always 
worse  in  temper  and  conduct,  and  was  apt  to  have  morbid 
suspicions  and  hallucinations  badly  afterwards.  At  times  he 
wDuld  request  to  be  put  into  his  bedroom  alone,  to  be  quiet 
and  out  of  the  way  of  the  temptation  of  assaulting  his  fellow- 
patients.  After  being  in  the  Asylum  two  years  he  had  a  short 
paroxysm  of  mania,  and  broke  open  his  room  shutter  and  got 
out,  but  was  recaptured  before  he  went  away.  He  afterwards 
said  that  the  voices  had  been  telling  him  to  go  and  throw  him- 
self over  the  Dean  Bridge,  which  is  the  chief  temptation  to 
dramatic  suicide  in  Edinburgh.  He  improved  much  after  that, 
and  took  no  epileptic  fits  on  one  occasion  for  eighteen  months, 
never  needed  seclusion,  got  the  parole  of  the  grounds,  and 
went  into  Edinburgh  to  see  his  relations  occasionally.     IS"o 


448  EPILEPTIC   INSANITY. 

suicidal  attempt  was  ever  tliought  of  by  me  then.  The  fits 
had  become  shghtly  more  frequent,  however,  in  spite  of  the 
bromide.  When  out  one  day  he  went  into  town  for  a  walk 
with  two  fellow-patients,  was  perfectly  chee-rful,  and  even 
jovial  j  met  his  brother,  and  chatted  pleasantly  with  him, 
saying  he  would  be  out  again  "next  Saturday."  On  his 
way  home  he  said  to  his  companions  that  he  was  going  to  a 
urinal,  went  down  a  bye  street,  and  then,  as  straight  as  he 
could  go,  he  made  for  the  Dean  Bridge  and  threw  himseH 
over,  kilhng  himself  instantly.  This  was  two  years  after  the 
time  he 'said  the  voices  told  him  to  do  so;  and  for  twelve 
months  before  he  might  have  gone  and  done  so  any  day, 
so  far  as  any  restraint  in  the  Asylum  was  concerned.  On 
post-mortem  examination,  I  found  the  pia  mater  over  the 
whole  vertex  of  the  brain  strongly  adherent  to  the  convolu- 
tions, and  the  ventricles  granular,  just  hke  a  typical  case  of 
general  paralysis.  In  fact,  I  never  saw  any  case  of  that 
disease  with  those  pathological  appearances  much  more 
marked,'  and  no  one  could  have  told  from  the  naked-eye 
appearances  that  it  was  not  a  case  of  general  paralysis. 

Homicidal  Tendencies. — The  homicidal  acts  of  epileptics 
are  done  under  the  most  various  circumstances,  are  widely 
different  in  character  in  different  cases,  and  even  in  the 
same  case  at  different  times,  sometimes  are  done  reasoningly 
from  conscious  insane  motives,  sometimes  apparently,  but  not 
really  reasoningly,  because  without  consciousness  or  memory. 
An  epileptic  may  scheme  to  do  an  act  of  insane  violence  and 
try  to  conceal  it  carefully  afterwards.  They  are  very  apt  to 
take  unfounded  dislikes,  especially  to  their  relations  and  those 
near  them.  The  conscious  anger  will  pass  into  the  epileptic 
unconscious  mania  in  a  moment  sometimes.  One  of  the  most 
extraordinary  things  I  ever  knew  was  this : — A  young  epi- 
leptic, H.  G.,  who  was  very  friendly  with  me  when  he  was 
well,  used  to  dislike  me  very  much  when  excited  after  fits. 
On  one  occasion  the  attendant  found  him  and  another  patient 
contriving  to  make  up  a  weapon,  with  which  to  assault  me  or 


EPILEPTIC   INSANITY.  449 

the  chief  attendant,  out  of  a  stocking  which  the  epileptic  had 
taken  off,  put  a  stone  in  the  toe  of  it,  tied  a  string  about  this, 
and  had  then  slipped  it  up  his  sleeve  till  he  should  have  a 
chance  of  using  it.  When  he  got  out  of  the  epileptic  mental 
condition  he  was  astonished  when  told  about  this,  and  said  he 
had  no  recollection  of  it  whatever,  which  I  beheved  to  be  true. 
The  combination  with  another  patient,  and  the  purposive  com- 
bined preparation  of  a  lethal  weapon,  all  in  a  state  of  epileptic 
altered  consciousness,  I  could  not  have  believed  possible  had 
I  not  seen  them  in  that  patient.  Supposing  this  man  had  not 
been  in  the  Asylum  and  had  combined  with  another  in  pre- 
paring a  weapon,  waiting  for  an  opportunity,'  and  had  com- 
mitted murder ;  and  then  supposing  a  doctor  had  gone  into 
the  witness-box  and  given  evidence  that  the  murderer  was 
quite  irresponsible  on  account  of  his  being  in  a  state  of  ej)i- 
leptic  insanity,  and  quite  unconscious  of  his  acts  at  the  time, 
with  what  lofty  scorn  would  the  judge  have  put  aside  such 
evidence  as  being  inherently  incredible !  With  what  dog-- 
matic  assertion  the  newspapers  would  point  to  such  an 
example  of  a  medical  man  trying  to  defeat  justice  and  screen 
a  criminal !  What  Uvely  ridicule  the  journals  would  have 
poured  upon  evidence  so  "opposed  to  common  sense  and  to 
law  "  !  And  all  this  because  a  fact  of  nature  and  of  disease 
had  been  brought  out  before  those  who  were  ignorant  of  the 
whole  subject. 

Pathology. — As  regards  the  pathology  of  epileptic  insanity, 
it  is,  like  the  pathology  of  epilepsy,  as  yet  very  obscure.  I 
have  met  with  innumerable  brain  lesions  of  almost  every  kind 
in  different  cases,  and,  on  the  other  hand,  I  have  most  care- 
fully examined  the  brains  of  many  epileptic  insane  persons, 
and  have  found  no  naked-eye  lesion  or  abnormality.  I  have 
found  the  following  amongst  other  lesions,  viz.,  spicula  of 
bone  from-  the  skull-cap  and  membranes  pressing  into  the 
convolutions,  apoplexies,  destructive  lesions  of  the  brain  of 
all  kinds  and  in  all  places,  embolisms,  fatty  and  otherwise, 
adhesions  of  the  pia  mater  to  the  convolutions,  the  marks  of 

2  F 


450  EPILEPTIC    INSANITY. 

traumatic  injuries  of  all  kinds  and  in  all  places  of  tlie  brain, 
unequal  hemispheres,  aiid  congestions  of  all  sorts  and  in  all 
places.  I  have  tried  my  hest  to  confirm  Shrceder  van  der 
Kolk's  observations  as  to  the  medulla  and  pons  being  always 
congested  or  diseased  in  epileptics.  I  have  certainly  failed 
to  do  so,  and  do  not  believe  that  it  is  the  case.  The  general 
result  of  my  pathological  observations  is,  that  any  source  of 
irritation  in  a  brain  of  a  certain  quality  may  cause  epilepsy,  ' 
but  that  an  irritation  to  the  motor  area  of  the  convolutions 
is  far  more  apt  to  cause  it  than  one  anywhere  else.  The  co- 
ordination of  the  convulsions,  and  the  breathing  difficulties 
of  the  actual  fit,  may  arise  in  the  medulla,  but  the  real  origin 
of  the  convulsions  is  usually  higher  up  in  the  brain.  To  have 
epilepsy  we  must  have  an  inherent  motor  instabihty  in 'the 
convolutions,  just  as  we  must  have  essential  mental  insta- 
bility in  the  convolutions  in  order  to  have  insanity  in  most 
cases.  The  epilepsy  is  an  occasio7ial  dynamical  disturbance, 
that  may  be  the  result  of  a  constant  pathological  lesion,  or  of 
an  inherently  morbid  brain  constitution.  It  is  a  remarkable 
fact  in  epilepsy  that  one  hemisphere  of  the  brain  is  in  nearly 
all  cases  found  considerably  heavier  than  the  other,  and  that 
in  by  far  the  majority  of  the  cases  of  infantile  paralysis  or 
unilateral  development,  where  one  hemisphere  of  the  brain  is 
larger  and  more  perfect  than  the  other,  such  patients  are  sub- 
ject to  epileptic  fits. 

Microscopic  Appearances. — Dr  Bevan  Lewis  dissents  from 
the  view  I  have  stated  above,  that  we  must  look  for  the 
pathology  to  a  morbid  quaHty  of  energising  in  the  motor 
cortex.  He  says  that  he  has  demonstrated  that  in  epileptics 
he  finds  that  the  small  irregularly  shaped  nerve-cells  occupy- 
ing the  position  of  the  second  layer  of  the  cortex,  exhibit  a 
degenerative  change,  which  is  so  far  peculiar  that  the  nucleus 
of  the  cell  is  the  earhest  portion  affected,  the  cell  protoplasm- 
being  apparently  secondarily  involved.  The  centre  of  the 
nucleus  is  occupied  by  an  extremely  bright,  highly  Tefractile 
spherical  body,  obviously  of   a  fatty  nature.     This  enlarges 


EPILEPTIC  INSANITY.  451 

until  they  have  vacuolation  of  the  nucleus  to  a  very  marked, 
and  Dr  Lewis  implies,  "universal"  extent.  The  cells  in  the 
other  layers  do  not  "  escape  a  similar  impHcation " ;  but  it 
may  only  "be  detected  here  and  there  in  the  small  and  large 
pyramidal  cells."  He  draAvs  attention  to  "the  persistence 
shown  by  the  nerve-cell  despite  the  degenerative  change  in 
its  nucleus,  and  it  is  only  later  on,  in  the  stage  of  dissolu- 
tion, that  the  cell  protoplasm  betrays  evidence  of  degenera- 
tion." He  beHeves  that  the  layer  of  cells  is  of  the  "  sensory 
type  of  nerve  element,  and  that  an  organic  connection  exists 
between  them  and  the  large  motor  elements  distributed  at  a 
lower  level."  He  believes  that  these  sensory  cells  "have  an 
inhibitory  control  over  the  subjacent  elements,  and  that  lack- 
ing such  control,  their  discharge  will  be  disturbed  from  its 
normal  condition,"  hence  the  epileptic  fits.  He  believes  that 
morbid  changes  in  the  cell  nucleus  "  are  constant  accompani- 
ments of  cerebral  disturbances  characterised  by  loss  of 
inhibitory  control."  He  thinks,  also,  that  through  heredity, 
there  exist  in  the  cortex  of  epileptics  "inflated  spheroidal" 
cells,  which  show  a  reversion  and  "  a  more  primitive  type  "  of 
brain  such  as  we  find  in  the  ape.  Lewis  does  not  confine  the 
vacuolated  cells  to  epileptics,  however,  but  says  they  occur  in 
other  diseases,  and  especially  alcoholic  brain  disease,  but  never 
to  so  marked  a  degree,  and  limited  to  such  special  cortical 
areas  as  in  epileptic  insanity. 

Other  observers,  working  by  his  methods,  have  not  been  able 
to  confirm  Lewis'  observations  on  this  most  important  point. 
He  does  not  say  whether  the  cases  he  examined  and  in  which 
he  found  those  vacuolated  layers  of  cells  were  chronic  or  recent 
epileptics,  or  both.  Drs  Middlemass  and  "W.  F.  Eobertson 
have,  in  the  laboratory  of  the  Royal  Edinburgh  Asylum,  care- 
fully examined  the  brain  by  Lewis'  method  in  many  cases  of 
epilepsy,  and  have  not  been  able  to  make  out  in  every  case 
the  vacuolation  and  nuclear  degeneration  with  protoplasmic 
soundness  as  described  by  him.  In  one  case,  a  developmental 
epileptic,  on  the  contrary  they  found  the  nuclei  of  the  cells 


452  EPILEPTIC   INSANITY. 

in  the  second  and  third  layers  intact,  while  the  cell 
protoplasm  had  undergone  most  marked  changes.'^  (Plate 
IX.  figs,  2  and  3.)  On  the  other  hand,  they  have  found  a 
nnclear  vacuolation  in  many  other  chronic  varieties  of 
insanity.  Of  four  epileptics  whose  brains  Dr  Middlemass 
carefully  examined,  the  motor  cortex  was  almost  normal  in 
two,  the  cortex  in  frontal  lobes  containing  a  few  cells  slightly 
granular  in  second  layer,  but  in  one  of  those  some  of  the  large 
cells  in  the  medulla  were  markedly  vacuolated  in  their  nuclei. 
In  the  third  case,  a  very  advanced  one,  in  whom  the  speech 
was  almost  lost,  there  was  very  marked  fatty  degeneration  of 
second  and  third  layers  in  the  cell  protoplasm,  which  was  also 
much  atrophied  in  many  cells,  while  the  nuclei  seemed  quite 
normal  all  over.  In  the  fourth  case  there  was  universal 
vacuolation  of  all  the  cells  of  every  layer  of  the  cortex.  It  was 
almost  impossible  to  find  a  normal  cell.     (Plate  IX.  fig.  1.) 

Epilepsy  a  Developmental  Neurosis.- — Almost  all  cases  of  true 
epilepsy  first  arise  during  the  growth  period  from  birth  up  to 
14,  or  the  developmental  (from  13  to  25)  period  of  life, 
Gowers  found  that  of  his  1450  cases  340  or  23  per  cent,  arose 
before  the  age  of  7 ;  other  28  per  cent,  arose  from  7  to 
13;  then  444  cases  or  31  per  cent,  arose  from  13  to  20; 
and  195  or  13  per  cent,  of  them  from  20  to  25.  There 
are,  therefore,  two  great  epilepto-genetic  periods,  the  first 
during  the  period  of  fastest  brain  growth  from  birth  to  7,  and 
the  next  during  the  last  period  of  slow  growth  but  rapid 
development  of  new  and  important  functions,  the  period  of 
puberty  and  early  reproduction,  from  13  to  18.  It  is  a 
strongly  hereditary  disease,  like  all  the  other  neuroses  of 
development. 

Treatment. — As  to  the  general  treatment  of  epileptic  insanity, 
it  is  that  of  epilepsy  with  that  of  mania  superadded ;  and 
with  special  precautions  to  combat  the  special  dangers  I  have 
described.  Give  the  bromides  regularly  and  steadily  as  you 
give  food  to  your  epileptics.  Find  out  the  dose  for  each  case 
^  The  Neuroses  of  Development,  by  tlie  author,  p.  104. 


EPILEPTIC   INSANITY.  453 

that  will  saturate  but  will  not  bromise,  wliicli  will  be  from.  40 
to  70  grains  a  day  in  different  cases.  Half  bromide  of  potas- 
sium, and  half  of  sodium,  with  one  or  two  minims  of  hquor 
arsenicalis  to  each  dose,  makes  a  capital  combination.  In 
some  cases  a  little  iron  added  will  do  good.  It  can  be  given 
for  years.  I  have  known  the  bromide  of  potassium  continued 
now  for  eighteen  years  in  a  case  with  immense  benefit  and  no 
harm  all  that  time.  Dr  Macphail  found  that  in  epileptics  "  the 
quality  of  the  blood  improves  during  treatment  with  bromide 
of  potassium,  and  the  prolonged  use  of  the  drug  exercises  no 
deteriorating  influence  in  decreasing  the  percentages  of  haemo- 
globin and  of  hgemocytes."^  Some  few  cases  will  not  be  bene- 
fited at  all,  but  four-fifths  will  be  so  more  or  less,  and  one-half 
will  be  benefited  very  much,  while  one-fourth  will  be  so  much 
benefited  as  to  be  practically  cured,  so  long  as  they  are  kept 
under  treatment.  Its  use  will  very  often  save  epileptics  being 
sent  to  asylums.  Any  physician  to  an  asylum  who  does  not 
keep  most  of  his  epileptic  patients  continuously  under  the 
influence  of  the  bromides  deliberately  disregards  one  of  the 
best-proved  of  therapeutic  facts,  for  I  have  proved  by  experi- 
ment that  he  can  reduce  the  fits  to  one-sixth,  taking  all  the 
epileptics  in  an  asylum  together,  and  practically  cure  some 
cases,  while  most  are  improved  mentally.^  Any  physician 
out  of  an  asylum  who  has  an  epileptic  to  treat,  and  sends 
him  into  an  asylum,  except  for  acute  dangerous  symptoms, 
without  trying  the  eff'ect  of  the  bromides,  does  not,  I  think, 
give  his  patient  the  best  chance  known  to  science.  Many 
patients  will  at  times  become  bromised,  but  the  white  tongue, 
mental  hebetude,  and  slow  muscular  movements  of  this  con- 
dition can  be  easily  seen  in  time  before  much  brain  harm  is 
done.  Intermittent  bromide  treatment  is  of  little  or  no  use. 
It  must  be  continuous  to  do  much  good.  Why  the  bromide 
does  good  to  epileptics  is  as  yet  not  ascertained  in  an  abso- 
lutely definite   scientific  way ;  but  my  belief,  founded  on  a 

^  Journal  of  Mentcd  Science,  January  1885. 
2  Ibid.,  October  1868. 


454  EPILEPTIC   INSANITY. 

very  extensive  experience  of  its  use,  is  that  its  therapeutic 
effects  are  closely  connected  with  its  physiological  actions  of 
— (1)  diminishing  the  irritability  of  nervous  tissue;  (2)  lessen- 
ing the  blood-pressure  in  the  capillaries ;  (3)  diminishing  the 
sexual  desire  and  the  reproductive  power ;  (4)  producing  a 
slowness  in  the  mental  operations  alHed  to  the  phlegmatic 
temperament.  In  addition  to  the  bromide  treatment,  dietetic 
regulation,  not  too  much  animal  food,  the  avoidance  of  sur- 
feits, plenty  but  not  too  much  exercise,  Kfe  in  the  fresh  air, 
no  excitement  that  can  be  avoided,  and  no  alcohol,  are  all 
useful.  I  have  several  epileptics  who  will  almost  certainly 
take  fits  or  become  irritable  if  they  either  go  to  a  dance  or 
get  two  glasses  of  whisky.  Blisterings  and  setons  do.  good 
in  some  cases,  whUe  ergot  and  conium,  especially  if  combined 
with  chloral,  sulphonal,  and  the  bromides,  will  control  out- 
bursts of  excitement.  Dr  Lewis  Bruce  uses  here  a  dose  of 
croton  oil  in  almost  every  case  where  an  attack  of  ej)Lleptic 
mania  is  showing  itself,  and  I  must  say  the  effect  seems  won- 
derfully good.  When  epileptics  take  many  fits  in  succession 
the  brain  functions  are  apt  to  get  more  and  more  retarded, 
till  the  patient  becomes  comatose,  the  breathing  stertorous,  and 
the  heart's  action  impeded  from  asphyxia.  This  is  the  Status 
Epilepticus,  for  which  chloral  is  strongly  recommended  by 
Lewis.  Dr  Walhs  recommends  bleeding  from  the  arm  for 
this  state  when  the  patient's  Hfe  seems  in  immediate  danger. 

The  moral  treatment  must  be  soothing  but  firm,  with  no 
arguing,  sharpness,  imperiousness,  nor  useless  verbal  con- 
tradiction. There  is  a  procedure  in  the  management  of 
cases  of  epilepsy  subject  to  maniacal  attacks  that  I  look  on 
as  of  the  greatest  importance  as  tending  to  prevent  attacks 
of  mania  coming  on.  It  is  founded  on  the  natural  history 
of  the  disease.  After  an  epileptic  fit  of  the  graver  kind,  a 
patient  is  always  necessarily  unconscious  at  first,  then  stupid 
and  confused,  and  then  sleepy,  and  if  he  is  favourably  situated 
he  goes  off  into  a  very  sound  sleep.  This  seems  to  me  nature's 
mode   of   restoring   the   disturbed   cerebral   circulation    and 


EPILEPTIC   INSANITY.  455 

recuperating  tlie  exhausted  organ.  Even  after  the  sleep  most 
epileptics  feel  tired  for  a  time.  JSTow,  by  carefully  giving  an 
epileptic  the  chance  of  sleeping  after  his  fits,  by  putting  him 
on  a  sofa  and  darkening  the  room,  we  aid  nature  in  her 
efforts  to  get  over  these  effects.  When  the  patient  will  not 
sleep,  but  shows  signs  of  being  restless  and  excitable,  give 
him  20  or  30  grains  of  chloral,  with  a  drachm  of  the  bromide, 
and  put  him  to  bed  in  a  dark  room.  The  chances  are  he 
will  sleep  soundly  and  long,  and  will  wake  up  all  right. 
I  have  seen  this  plan  succeed  in  apparently  averting  outbursts 
of  epileptic  mania  dozens  of  times. 

As  regards  the  results  of  treatment,  they  are  in  one  way 
unsatisfactory  from  the  risk  of  relapse,  and  in  another  way 
satisfactory,  because  the  patients  may  go  home  from  asylums 
and  earn  their  livelihood,  and  enjoy  their  liberty  for  long 
periods,  often  for  life,  if  they  will  persevere .  in  suitable 
treatment.  A  patient  recovered  from  epileptic  insanity  may, 
while  he  is  well,  be  quite  as  well  as  a  woman  recovered  from 
puerperal  insanity.  Our  results  in  the  Morningside  Asylum 
for  the  ten  years  1873-82  have  been,  that  out  of  128  cases 
admitted,  31,  or  -24  per  cent.,  have  been  discharged  recovered 
of  their  epileptic  insanity,  and  with. the  epilepsy  itself  greatly 
modified.  Many  of  these  have  been  able  to  remain  at  home. 
And  it  must  be  remembered  that  the  cases  sent  to  asylums 
are  the  worst  cases  of  the  disease.  The  milder  cases,  with 
infrequent  attacks,  are  often  treated  at  home  very  satis- 
factorily. 

Local  Prevalence. — Epileptic  insanity  prevails  very  dif- 
ferently in  different  parts  of  this  country.  In  the  southern 
agricultural  counties  of  England,  where  wages  are  low,  life 
is  stagnant,  food  is  not  too  abundant,  and  beer  is  almost 
universally  used  as  a  part  of  the  dietary,  epileptic  insanity  is 
unusually  common — ^standing  over  11  per  cent,  of  all  the 
admissions,  and  in  some  of  them  forming  about  one-fourth 
of  all  the  inmates  in  the  county  asylums  of  those  districts. 
This-  includes   the  epileptic   idiocy    and   imbecility,   as   well 


456  EPILEPTIC   INSANITY. 

as  the  cases  where  the  epilepsy  arose  later  in  hfe.  In  such 
parts  of  the  country  the  former  kind  of  epileptic  insanity 
prevails  much  more  than  the  latter.  In  the  better-off  mining 
and  manufacturing  counties,  such  as  Durham,  Glamorgan, 
Stafford,  &c.,  and  in  some  counties  of  mixed  population  such 
as  Sussex,  the  proportion  of  epileptic  insanity  in  the 
admissions  is  only  about  5  per  cent.  Chnically,  epileptic 
insanity  is  more  acute  and  typical  in  those  districts.  In  the 
large  cities  of  England  it  holds  an  intermediate  place,  forming 
about  8  per  cent,  of  the  admissions  to  the  asylums  of  those 
cities.  In  Scotland  it  prevails  to  "a  less  extent  than  in 
England.  In  the  admissions  to  the  Royal  Edinburgh 
Asylum,  Avhose  pauper  patients  are  drawn  entirely  from  a  city 
population,  only  4  per  cent,  have  laboured  under  epileptic 
insanity  during  the  past  nine  years,  and  only  7  per  cent,  of 
our  present  inmates  are  of  this  class,  and  it  is  a  curious  fact 
that  in  our  department  for  the  richer  classes,  to  which  about 
800  cases  have  been  admitted  in  the  past  nineteen  years,  only 
one  epileptic  has  been  sent.  In  other  parts  of  Scotland  it  is 
still  more  infrequent. 

(The  following  is  the  general  summary  and  conclusions 
of  my  experiments  made  in  1867  to  determine  the  precise 
effects  of  the  bromide  of  potassium  in  epilepsy  and  epileptic 
insanity.) 

Twenty-nine  cases  of  epilepsy  of  old  standing,  all  having  tlie  same 
diet,  and  subject  to  the  same  conditions,  were  subjected  to  systematic 
treatment  by  bromide  of  potassium,  after  their  normal  condition  as'  to 
fits,  weight,  temperature,  general  health,  and  mental  state  had  been 
ascertained  and  noted.  I  gave  them  gradually  increasing  doses  of  the 
medicine  from  5  grains  up  to  50  grains  three  times  a  day,  and  the  treat- 
ment was  continued  for  thirty-eight  weeks,  every  essential  particular  in 
regard  to  the  disease  and  their  bodily  and  mental  condition  being  noted 
every  week  during  that  time. 

The  total  number  of  tits  taken  by  the  patients  fell  gradually  under 
the  use  of  the  medicine  to  one-sixth  of  their  average  number  without 
medicine. 

The  fits  taken  during  the  day  were  lessened  to  about  one-twelfth,  and 
those  taken  during  the  night  to  about  one-third  of  the  previous  number. 

The  reduction  in  the  fits  was  not  uniform  m  all  the  cases.     In  one 


EPILEPTIC   INSANITY.  457 

case  it  amounted  to  their  abolition,  in  one-half  of  them  to  less  than  half, 
and  in  five  cases,  one-sixth,  there  was  no  reduction  at  all. 

In  one-fourth  of  the  cases  the  fits  were  much  less  severe,  in  some  being 
less  severe  while  as  frequent  as  before. 

In  one-fourth  of  the  cases  the  patient's  mental  state  was  very  greatly 
improved.  Nervous  and  mental  irritability  and  tendency  to  sudden 
violence  were  wonderfully  diminished  in  those  cases,  and  they  were  the 
worst  of  the  patients  in  that  respect. 

Attacks  of  epileptic  mania  were  diminished.  In  some  cases  the  mental 
state  was  improved,  while  the  fits  remained  as  frequent  as  ever. 

The  majority  of  the  patients  gained  considerably  in  weight  while  the 
doses  were  under  35  grains  three  times  a  day.  Their  aggregate  weight 
was  greater  at  the  end  of  the  thirty-eight  weeks  than  it  had  been  to 
begin  with,  though  it  began  to  fall  after  35-grain  doses  had  been  reacht  d. 

The  patients'  average  temperature  fell  somewhat  until  they  got  to' 
50-grain  doses  thrice  a  day. 

The  pulse  gradually  fell  about  seven  beats  up  to  40-grain  doses.  After 
that  it  rose,  but  not  up  to  its  usual  standard  without  medicine. 

None  of  the  patients  suffered  in  their  general'  health  except  five.  All 
the  others  were  benefited  in  some  way. 

The  ill  efi"ects  produced  by  the  medicine  in  those  five  cases  were  torpor 
of  mind  and  body,  drowsiness,  increase  of  temperature,  loss  of  weight, 
loss  of  appetite,  and  in  three  of  them  slight  double  pneumonia. 

The  cases  most  benefited  by  the  drug  were  very  various  as  to  the 
causes,  number,  and  character  of  the  fits,  age,  and  in  every  other  respect. 
On  the  whole,  the  cases  who  took  most  fits  benefited  most. 

The  cases  in  whom  the  medicine  had  ill  eff"ects  had  all  taken  fits  from 
childhood,  were  all  very  demented  in  mind,  and  took  more  than  one  fit 
per  week,  but  seemed  to  have  nothing  else  in  common. 

The  diminution  of  the  fits  and  all  the  other  good  effects  of  the 
medicine  reached  their  maximum  in  adults  at  30-grain  doses  three  times 
a  day,  while  ill  effects  were  manifested  when  35-grain  doses  three  times 
a  day  were  reached. 

There  seemed  to  be  no  seriously  ill  effects  produced  in  twenty  of  the 
cases  by  50-grain  doses  of  the  medicine  thrice  a  day  continued  for  ten 
weeks. 

When  the  medicine  was  entirely  discontinued  for  a  month  in  all  the 
cases,  the  average  number  of  fits  increased  in  five  of  the  cases  benefited 
to  or  beyond  their  original  number,  in  thirteen  cases  they  remained  con- 
siderably less. 

The  average  number  during  that  time  was  a  little  more  than  one-half 
the  number  of  fits  taken  before  the  medicine  was  given,  and  the  greatest 
number  of  fits  occurred  in  the  second  week  after  the  medicine  was  dis- 
continued. 


458  TKAUMATIC  INSANITY. 


TRAUMATIC  mSANITY. 

Definition — Sunstroke — Symptoms — Motor  symptoms,  two  kinds — Case 
of  Traumatic  Insanity,  cured  by  Trephining — Traumatism  acting  as 
exciting  cause  of  ordinary  insanity — Prevalence. 

A  few  cases  of  mental  disease  are  caused  by  blows  on  tlie 
head,  falls,  and  other  traumatic  injuries  to  the  brain.  Sun- 
stroke also  causes  insanity,  and  the  general  mental  symptoms 
of  traumatism  and  sunstroke  are  apt  to  be  alike.  ISTo  doubt 
sunstroke  gets  the  credit  of  far  more  insanity  than  it  pro- 
duces. Few  Britons  become  insane  in  hot  chmates  in  whom 
that  cause  is  not  assigned.  My  experience  is  that  traumatic 
insanity  is  to  be  found  in  two  forms.  The  first  form  is  the 
more  characteristic  type  of  the  disease.  It  is  accompanied 
by  motor  symptoms,  in  the  shape  of  speech  difficulties, 
slight  hemiplegia,  general  muscular  weakness,  or  convulsions. 
Usually  in  such  cases  there  are,  in  addition,  sensory  symptoms, 
such  as  cephalalgia,  vertigo,  hallucinations,  a  feeling  of  con- 
fusion and  incapacity  for  exertion  of  any  kind,  mental  or 
bodily.  The  mental  symptoms  are  usually  a  form  of  melan- 
cholia at  first,  tending  in  time  towards  an  irritable  and  some- 
times impulsive  and  dangerous  dementia  or  delusional  insanity. 
In  my  experience  such  cases  are  all  absolutely  intolerant  of 
alcohohc  stimulants,  a  very  little  of  which  will  always  make 
them  maniacal,  and  often  very  dangerous  and  even  homicidal. 
Many  of  them  have  a  craving  for  stimulants,  too,  which  they 
indulge,  and  which  aggravates  all  their  symptoms.  It  is 
surprising  what  a  number  of  the  traumatic  cases  are  com- 
plicated with  alcohol,  in  having  been  addicted  to  drink  before 
these  accidents,  or  taking  to  it  after.  Over  one-half  of  my 
cases  were  so  complicated.  In  either  case,  whether  a 
drunkard  falls  and  injures  his  brain  and  becomes  insane,  or 
whether  a  man  takes  to  drink  and  becomes  insane  after  an 
injury,   the    alcohol   aggravates   the   mental   symptoms,  and 


■  TRAUMATIC   INSANITY.  459 

tends  more  strongly  towards  incurability  than  mere  uncom- 
plicated traumatism. 

Motor  Symptoms. — A  few  cases  become  ordinary  epileptics. 
I  have  two  epileptics  in  the  Eoyal  Asylum  now  who  have 
large  depressed  fractures,  and  I  have  seen  several  more  on  the 
post-mortem  table.  In  one  there  had  been  a  fracture  above 
the  ear,  where  the  bone,  membranes,  and  brain  all  adhered  by 
an  old  inflammation.  I  have  seen  three  patients  now,  in  whom 
the  motor  symptoms  were  so  exactly  those  of  general  paralysis 
that  I  diagnosed  them  as  such,  but  they  turned  out  to  be  non- 
progressive, though  not  curable  paralytic  cases ;  and  now, 
after  over  ten  years,  they  are  alive,  and  no  worse  than  at  first. 
One  man,  H.  H.,  fell  off  a  ladder,  and  fractured  the  base  of 
his  skull,  was  unconscious  for  long,  and  seemed  afterwards  to 
become  a  true  general  paralytic  from  this  cause,  but  his  symp- 
toms did  not  progress.  Another,  H.  I.,  a  drunkard,  received 
an  injury  to  his  head,  was  unconscious,  and  seemed  to  become 
mentally  and  bodily  a  typical  general  paralytic,  but  the  motor 
symptoms  never  progressed.  As  I  mentioned,  traumatism  is 
one  of  the  rare  causes  of  true  general  paralysis.  I  had  one 
such  case  that  was  caused  by  a  railway  collision,  but  then  the 
man,  after  the  accident,  attempted  to  study  and  enter  a  pro- 
fession with  a  weakened  brain  and  an  impaired  memory. 
Within  three  years  he  became  a  general  paralytic,  and  died 
of  the  disease. 

Usually  the  motor  symptoms  of  traumatic  insanity  are  non- 
progressive, or  very  slowly  so.  But  they  do  not  always  mani- 
fest themselves  at  once  after  the  injury.  I  had  one  patient, 
H.  L.,  who  was  not  made  unconscious  at  all  by  the  blow  of  a 
piece  of  wood  falling  on  his  head,  but  who  gradually  in  three 
months  got  weaker  on  one  side,  as  well  as  being  muscularly 
weak  all  over,  and  also  mentally  impaired  in  memory,  energy, 
and  vohtional  power.     He  was  also  very  irritable. 

Certain  very  interesting  cases  have  been  recorded  of  insanity 
directly  following  fractures  of  the  skull,  with  consequent  pres- 
sure on  the  brain,  which  were  cured  by  trephining  or  raising 


460  TKAUMATIC  INSANITY. 

the  depressed  bone.  One  of  the  most  striking  of  these  was 
piibHshed  by  Dr  Charles  H.  Skae.^  It  was  that  of  a  miner 
who  received  a  depressed  fracture  of  the  skull  about  three 
inches  above  the  left  extremity  of  the  left  eyelid,  was  un- 
conscious for  four  days  afterwards,  then  went  to  work,  but 
within  a  fortnight  exhibited  a  change  of  disposition  and  habit. 
Instead  of  being  a  sociable,  merry,  good-natured  man,  fond 
of  his  wife  and  children,  he  became  at  first  irritable,  moody, 
unsocial,  and  susjpicious,  then  excited  and  dangerous,  and  then 
acutely  maniacal.  He  was  sent  to  the  Ayr  Asylum,  and  two 
months  after  admission,  during  which  time  he  had  not  im- 
proved, an  operation  Avas  performed  by  Dr  Clarke  "Wilson,  by 
which  the  depressed  portion  of  bone  was  removed.  A  gradual 
improvement  in  mind  took  place  week  by  week  after  this, 
until  in  a  short  time  he  was  as  sociable,  lively,  and  cheerful 
as  ever,  and  has  continued  so  ever  since. 

Such  cases  are  very  suggestive  of  thought  and  inquiry  as  to 
the  possible  reflex  and  direct  irritations  that  may  be  the  causes 
of  mental  disease  in  many  cases,  and  they  clearly  show  that 
the  general  dynamical  brain  disturbance  that  we  call  insanitj^ 
may  sometimes  originate  in  special  points  of  local  brain 
irritation. 

The  condition  of  the  urine  as  to  sugar  and  albumen  should 
be  carefully  tested  in  all  traumatic  cases.  Where  sugar  exists 
there  is  room  for  grave  suspicion  of  miscliief  to  the  pons  near 
the  floor  of  the  fourth  ventricle,  though  this  can  scarcely  be 
diagnosed  with  certainty  in  this  way. 

Some  cases  of  idiocy  result  from  injury  to  the  brain  by 
the  forceps  during  delivery,  and  I  have  two  now  in  the 
Royal  Asylum  resulting  from  falls  on  the  head  in  early 
childhood. 

The  other  and  less  distinct  class  of  traumatic  cases  are  those 

in  whom  an  injury  to  the  brain  acts  as  an  exciting  cause  of 

an  ordinary  attack  of  insanity  in  a  person  predisposed  to  the 

disease — in  fact  where  traumatism  acts  hke  a  moral  shock. 

^  Journal  of  Mental  Science,  vol.  xix.  p.  552. 


TKAUMATIC   INSANITY.  461 

As  tlie  result  of  a  bout  of  drinking  or  some  such  disturbing 
cause  of  brain  action  after  traumatism,  I  have  seen  attacks  of 
mania  and  melancholia  in  patients,  from  which  they  recovered 
perfectly ;  and,  on  the  other  hand,  I  have  now  under  my  care 
several  cases  of  ordinary  dementia,  and  one  of  chronic  mania, 
and  one  of -dehxsional  insanity,  all  incurable,  and  originating 
in  traumatism,  but  without  any  motor  or  sensory  signs,  and 
without  progression  of  symptoms.  I  once  saw  a  young  man, 
H.  M.,  of  19,  who  had  an  attack  of  ordinary  acute  mania  just 
after  being  in  a  railway  accident,  and  presumably  caused  by  it, 
but  by  Avhich  he  had  not  been  made  unconscious,  or  even 
stunned. 

/  have  now  a  case  of  suicidal  melancholia,  H.  M.  A.,  aet.  46, 
resulting  directly  from  an  injury  to  his  head  through  a  piece 
of  stone  falling  on  it  from  a  height  of  10  feet,  and  then  his 
falling  20  feet  on  the  back  of  his  head  off  the  scaffold  on  which 
he  was  working,  cutting  the  skin  over  the  occiput,  but  neither 
injury  causing  prolonged  unconsciousness.  This  occurred  three 
months  ago,  and  ever  since  he  has  been  able  to  do  no  work, 
has  suffered  from  a  dull  feeling  in  his  head  and  much  pain  in 
his  back.  His  mental  condition  became  gradually  depressed. 
His  attention  was  concentrated  on  his  ailments,  until  he  was 
quite  melancholic.  He  became  suicidal,  fancied  he  passed 
only  blood  from  his  bowels,  which  was  a  delusion,  and  that  his 
food  did  him  no  good,  he  being  fairly  nourished.  There  were 
no  motor  signs,  and  his  temperature  was  normal,  the  reflexes 
being  also  normal,  but  he  did  not  sleep.  He  gradually  im- 
proved under  treatment,  until  he  became  well  in  mind  and 
body  and  able  for  his  work.  In  the  case  of  insanity  coming 
on  after  railway  accidents,  or  of  mental  symptoms  short  of 
"  technical  insanity  "  appearing  or  being  simulated,  we  need 
to  be  very  careful  indeed  in  our  conclusions  as  to  causation. 
Especially  if  the  mental  symptoms  are  chiefly  subjective,  we 
must  remember  there  is  a  motive  to  exaggerate  them  till  the 
damages  are  paid  by  the  company. 

Prevalence  of  Traumatic  Insanity. — We  have  had  twelve 


462  TRAUMATIC   INSANITY. 

cases  of  traumatic  insanity  and  the  insanity  of  sunstroke  sent 
to  the  Royal  Edinburgh  Asylum  in  the  past  nine  years,  which 
is  only  one-third  per  cent,  of  the  admissions.  Accidents  to  the 
head  do  not  seem  to  loom  largely  therefore  in  the  production 
of  the  insanity  of  the  world. 


LECTUEE  XII. 

SYPHILITIC  INSANITY. 

Syphilis  of  brain  not  common  ;  often  no  sypliilitic  affections  elsewhere, 
and  few  secondary  symptoms  ;  often  lies  long  dormant ;  effect  of 
hereditary  predisposition  to  the  neuroses  in  determining  the  occur- 
rence of  brain  syphilis  ;  no  syphilis  of  neurine  but  of  fibrous  tissues, 
neuroglia,  and  blood-vessels,  &c. — Syphilitic  insanity:  four  forms 
— 1.  Short  maniacal  attack  during  secondary  stage,  2.  The  Delu- 
sional. 3.  That  dependent  on  arteritis  in  brain ;  change  of 
character  ;  irritability  ;  immorality  ;  speech  difficulties  ;  dementia  ; 
paralysis ;  convulsions ;  neuro-retinitis.  4.  Syphilomatous  mass 
growing  in  convolutions  causing  acute  mania  ;  convulsions  ;  intense 
cephalalgia;  fever;  speedy  death.  Syphilitic  deposits  and 'inflam- 
mations in  membranes,  bones,  &c.,  affecting  convolutions  second- 
arily ;  symptoms  various  as  the  loctts  in  quo ;  partial  paralysis  ; 
ilfo?to-spasms ;  neuroses  of  sensibility ;  neuro-retinitis ;  speech 
troubles  ;  mania  ;  gradual  dementia  —  Prognosis :  In  1st  form 
good  ;  2nd,  bad  ;  3rd,  depends  on  stage  ;  4th,  bad,  but  may  be  good 
if  treatment  early — Treatment :  that  of  secondary  and  tertiary 
syphilis  ;  immense  value  of  the  iodide  of  potassium  in  large  doses 
long  continued — Differential  diagnosis  from  general  paralysis  and 
ordinary  epilepsy. 

The  mental  as  well  as  the  bodily  symptoms  of  brain  syphilis 
have  attracted  more  attention  on  the  continent  than  in  this 
country,  though  of  late  years  a  greater  medical  interest  has 
been  awakened  here  in  regard  to  this  subject  by  the  writings 
of  Eeade,  Buzzard,  Broadhurst,  and  Dowse,  but  above  all  by 
those  of  Hutchinson  and  Hughlings  Jackson.  It  is  a  large 
subject,  because  the  functions  affected  are  numerous;  an 
obscure  subject,  because  the  effects  of  the  disease  are  often 
very  slight  and  slow  in  development,  and  are  multifarious  in 
kind  ;  and  is  an  interesting  subject  to  the  alienist,  because  it 


464  SYPHILITIC   INSANITY. 

is  a  disease  in  which  the  mental  and  bodily  symptoms  can  after 
death  be  often  directly  connected  with  the  pathological  lesions 
present,  and  because  in  some  cases  the  resources  of  thera- 
peutics are  most  powerful  and  direct  in  curing  the  disease. 
In  regard  to  the  frequency  of  syphilitic  affections,  there  is  the 
most  extraordinary  difference  of  experience  among  different 
authors.  Dowse  makes  the  astounding  statement  that,  of 
10,000  patients  under  his  treatment  at  the  Central  London 
Sick  Asylum,  three-fourths  were  the  subjects  of  acquired  or 
hereditary  syphilis.  That  statement  is  enough  to  make  one 
shudder.  Its  import,  if  a  fact,  to  the  mental  and  bodily  future 
of  London  is  appalling.  Whatever  may  be  the  frequency  of 
ordinary  syphihtic  affections,  all  authors  agree  that  brain 
syphilis  is  rare,  absolutely  and  relatively.  Dr  Wilks  first 
pointed  out  "  that  when  the  primary  and  secondary  manifesta- 
tions of  syphihs  are  least  marked,  the  viscera  and  nervous 
system  are  affected  in  an  inverso  ratio  "  ;  that  is,  we  find  that 
in  a  large  number  of  cases  of  brain  syphilis  there  had  been  few 
primary  or  secondary  symptoms,  and  no  trace  of  the  effects  of 
the  disease  in  the  viscera.  My  own  observation  confirms  that 
of  others,  that  the  syphilis  which  ultimately  attacks  the  brain 
or  its  membranes  has  often  lain  for  many  years  entirely  latent, 
or  apparently  so,  before  it  produced  any  symptoms  at  all.  I  think 
there  is  no  doubt. that  a  hereditary  predisposition  towards  the 
neuroses  determines  the  effects  of  the  poison  towards  the  brain. 
In  addition,  injury  to  the  brain,  previous  disease,  venereal  ex- 
cesses, over-study,  mental  anxiety  or  worry,  and  even  fright, 
may  all  act  as  determining  causes  of  brain  syphilis.  Lancereaux 
states  that  the  learned  professions  are  especially  hable  to  it. 

Looking  at  the  matter  from  a  purely  pathological  point  of 
view,-  "  syphilis  of  the  nervous  system,"  though  a  term  often 
used,  is  strictly  speaking  a  misnomer,  for  Hughhngs  Jackson 
has  shown  that  the  poison  never  really  attacks  the  nerve  tissue 
proper  at  all,  but  only  its  neuroglia,  fibrous  tissue,  blood- 
vessels, lymphatics,  membranes,  or  bony  coverings,  involving 
the  nerve  tissue  and  its  functions  secondarily,  by  pressure,  so 


SYPHILITIC  INSANITY.  465 

causing  irritation,  inflammation,  and  ramoUissement,  or  by 
starvation  from  deficient  blood-supply,  and  so  causing  de- 
generation and  atro|)liy. 

Brain  syphilis  with  mental  symptoms  is  in  this  unique 
position,  that  in  the  most  characteristic  cases  its  pathology 
is  much  more  definite  than  its  symptoms.  The  pathological 
changes  may  involve  any  and  every  part  of  the  brain,  and  in 
any  and  every  degree.  The  symptoms  therefore,  mental  and 
bodily,  depend  on  the  position  and  on  the  intensity  of  the 
morbid  processes.  We  may  have  the  most  acute  and  delirious 
mania  caused  by  a  rapidly  growing  destructive  syphiloma  in 
the  convolutions,  or  we  may  have  a  mental  enfeeblement  so 
slowly  progressing  that  it  takes  twenty  years  to  run  its  course, 
caused  by  an  obstructive  arteritis  gradually  closing  up  the 
lumen  of  a  few  of  the  cerebral  blood-vessels. 

Four  Forms. — My  own  experience  would  lead  me  to 
classify  syphilitic  insanity  into  four  forms ;  and  here  I  am 
conscious  of  the  disadvantage  I  am  under  in  having  chiefly 
to  do  with  the  mental  symptoms  of  brain  syphilis,  instead 
of  having  to  treat  of  the  whole  subject  with  its  whole  bodily 
and  mental  symptoms.  The  brain  syphilis  that  has  bodily 
symptoms  only  I  see  little  of,  though  its  pathology  and  treat- 
ment may  be  precisely  the  same  as  the  mental  cases,  the  only 
difi'erence  being  the  locus  in  quo.  The  mere  sketch  I  am  able 
to  give  here  of  the  mental  symptoms  will  by  no  means  exhaust 
the  great  variety  of  psychological  phenomena  met  with  in  this 
disease. 

The  first  form  may  he  called  secondary  syphilitic  insanity. 
It  occurs  during  the  second  stage  of  the  disease,  is  coincident 
with  the  eruption,  is  curable  and  rare.  Dr  Cadell  ^  has  de- 
scribed a  typical  case.  A  gentleman  contracted  an  infecting 
chancre  in  January.  A  squamous  syphiKde  appeared  in 
April,  and,  along  with  it,  marked  mental  excitement  and  an 
extreme  amount  of  motor  restlessness,  this  maniacal  state 
reaching  its  height  in  August  and  September,  and  then  almost 

^  Juurncd  of  Mental  Science,  vol.  xx.  p.  564. 

2  G 


466  SYPHILITIC   INSANITY. 

amounting  to  delirmm.  "  The  patient  took  no  rest  in  bed, 
was  in  the  habit  of  riding  and  driving  about  recklessly  during 
the  night."  This  maniacal  excitement  gradually  diminished, 
until  in  December  the  patient  appeared  to  be  in  his  normal 
mental  state,  tliis  being  coincident  with  the  gradual  disappear- 
ance of  the  syphiHde.  In  the  following  April,  an  attack  of 
mild  suicidal  melancholia  with  "  paralysis  of  energy  "  came 
on,  and  lasted  for  over  a  year,  this  being  coincident  with 
the  falKng  out  of  the  hair  of  the  head,  eyebrows,  and  beard. 
With  the  disappearance  of  all  traces  of  the  syphihs,  and  the 
restoration  to  bodily  health,  the  mental  state  also  became 
normal,  and  remained  so. 

I  had  a  case,  H.  0.,  a  young  woman  of  20,  who  seemed  to 
have  contracted  syphilis  either  just  before  or  just  after  her 
recent  marriage,  and  on  admission  to  the  Asylum  showed  the 
characteristic  eruption  of  the  second  stage,  with  sore  throat 
and  reduced  condition.  For  eight  days  before  admission  she 
had  been  maniacal,  and  when  sent  here  was  almost  incoherent, 
very  uncivil,  and  foul  in  her  language,  being  especially  erotic 
and  nasty  in  her  ideas.  She  had,  as  well  as  the  syphilitic 
eruption,  bronchitis  with  some  amount  of  pleurisy.  She  was 
put  on  iodide  of  potassium,  with  a  Ufctle  mercury,  and  tonics 
and  nutrients.  She  gradually  improved  in  mind,  the 
sypliihtic  eruption  passed  away,  but  her  lung  disease  went 
on,  and  of  that  she  died  within  six  months. 

K'ow,  such  cases  might  be  thought  to  be  mere  coinci- 
dences of  an  attack  of  mania  with  one  of  syphilis,  were  the 
beginning  and  termination  of  both  diseases  not  so  contempo- 
raneous. I  presume  such  moral  causes  of  insanity  as  fear,  re- 
morse, and  shame  come  in  and  help  the  blood  poison  to  start 
the  psychosis  in  such  cases  sometimes.  But  it  would  be 
strange  if  the  infection  of  the  system  and  of  the  blood  with 
such  a  virulent  and  vile  poison  did  not  sometimes  derange  the 
functions  of  the  convolutions  in  persons  predisposed  to  insanity. 
This  form  of  syphilitic  insanity  has  no  known  pathology.  Its 
treatment  is  that  of  secondary  syphihs,  and  its  prognosis  is  good. 


SYPHILITIC  INSANITY.  467 

The  second  fm^m,  the  delusional  sypMlitic  insanity,  is  one 
due,  vct  my  opinion,  to  slight  brain  starvation  from  an  obscure 
syphilitic  irritation  that  has  become  arrested.  It  consists  of 
a  monomania  of  suspicion  or  of  unseen  agency,  with  hallucina- 
tions of  the  senses,  and  sensory  perversions,  but  without 
motor  symptoms,  following  at  some  distance  of  time  an 
attack  of  syphilis  in  persons  strongly  predisposed  to  insanity. 
It  seems  as  if,  in  fact,  the  syphilitic  poison  had  produced  a 
subtle  dynamical  change  in  the  brain  convolutions  and  their 
trophic  energy  as  well  as  the  arteritis,  manifesting  itself  in 
unreason,  hallucinations,  and  an  organic  feeling  of  ill-being. 
Pr  Hugh  Grainger  Stewart  published  several  graphic  cases  of 
this  kind.  One  of  them  imagined  he  underwent  a  kind  of 
nightly  torture,  called  by  him  the  "  cylinder  finish  " ;  another 
said  that  most  ingenious  machines  were  introduced  into  her 
brain  to  torture  her;  another  that  people  shot  vitriol,  ammonia, 
and  "  black  poison "  at  him  all  night,  to  avoid  which  he 
wedged  his  bedroom  doors,  covered  the  keyholes  with 
blankets,  stuffed  his  ears  and  nostrils  with  cotton-wool  and 
his  mouth  with  a  pocket  handkerchief,  aU  these  defensive 
measures  against  his  imaginary  bombardment  taking  him  an 
hour  to  carry  out  before  he  went  to  bed.  I  have  several 
cases  of  the  same  kind  under  my  care  just  now.  One  is  a 
woman,  H.  P.,  a  prostitute,  who  thinks  there  is  a  network  of 
wires  in  her  brain,  put  there  by  me.  Another,  a  gentleman, 
H.  Q,,  strongly  predisposed  to  insanity,  his  only  sister  being 
insane,  who,  a  year  or  two  after  a  bad  attack  of  syphilis,  and 
while  some  of  its  constitutional  effects  still  remained,  de- 
veloped delusions  of  a  conspiracy  against  him,  and  that 
people  affected  him  sexually  at  night.  Under  the  influence 
of  these  delusions  he  became  dangerous.  Such  cases  are,  in 
my  experience,  almost  always  incurable.  They  are  liable  to 
be  complicated  by  alcoholic  and  phthisical  causes  of  brain 
disturbance.  I  admit  that  it  may  fairly  be  asked  about  such 
cases  —  Can  we  not  have  those  symptoms,  without  the 
occurrence  of  syphilis  at  all  ?     I  think  we  can.     Or  is  there 


468  SYPHILITIC   INSAi^ITY. 

sucli  proof  in  any  of  those  patients  that  have  been  syphihtic 
that  this  j)oison  or  its  trophic  effects  were  really  the  causes 
of  the  mental  derangement  ?  In  many  of  them  certainly  the 
time  between  the  supposed  cause  and  its  effects  was  long, 
and  altogether  the  scientific  proof  of  their  connection  is  weak. 
Still  the  coincidence  of  this  type  of  case  with  previous  severe 
attacks  of  syphilis  is  certainly  very  marked  in  a  large  number 
of  cases.  There  is  a  general  resemblance  between  the  mental 
symptoms  of  such  cases  and  those  of  the  case  of  the  ^^ vascular 
syphilitic  insanity  "  where  marked  disease  is  found  in  the 
arteries  of  the  brain. 

The  next  two  forms  have  a  very  definite  pathology.  One, 
the  third  on  the  list,  may  be  called  the  vascular  syjjhilitic 
insanity,  and  the  fourth,  the  "  syphilomatous  insanity."  -^  The 
one  depends  on  the  tendency  of.  the  poison  to  afi'ect  the 
blood-vessels  of  the  brain  and  cause  slow  arteritis,  with 
diminished  blood-carrying  capacity  and  consequent  slow  star- 
vation of  the  cerebral  tissue.  The  other  depends  on  the 
tendency  of  the  poison  to  affect  the  connective  tissue, 
membranes,  and  bones,  and  cause  pressure,  irritation  direct 
and  reflex,  and  inflammation  in  the  convolutions.  Any 
causes  of  arteritis  or  tumour  or  pressure  or  irritation 
other  than  syphilis  would  probably  produce  somewhat  the 
same  mental  symptoms;  and,  as  a  matter  of  fact,  some  of 
those  mental  symptoms  foUow  non-specific  arteritis  and 
tumours,  and  also  traumatic  lesions  of  the  brain.  Yet  the 
syphilitic  cases,  though  not  absolutely  pathognomonic,  are 
nearly  so  in  most  instances. 

Vascular  Syphilitic  Insanity. — Of  the  vascular  syphilitic 
insanity  I  give  the  two  following  cases  out  of  many  I  have 
met  with,  because  they  are  very  typical : — H.  E.,  when  he 
was  a  student,  was  infected  with  syphiHs,  which  ran  a  bad 
course,  and  many  of  its  somatic  efi"ects  never  left  him,  e.g., 
copper-coloured  spots  and  baldness,  and,  as  we  shall  see,  his 
liver  was  the  seat  of  an  old  gummatous  deposit.  He  entered 
^  Mr  Hayes  Newingtoii,  Journal  of  Mental  Science,  vol.  xii.  p.  555. 


SYPHILITIC   INSANITY.  469 

the  cliurch,  married,  and  procreated  several  unhealthy  children, 
one  of  whom  became  insane,  suffering  from  repeated  attacks 
of  mania.  In  twelve  years  after  his  attack  of  syphilis  he 
became  changed  mentally  and  morally,  showing  a  morbid 
irritability,  threatening  violence  to  his  wife  and  children, 
disregarding  the  decencies  of  life  and  the  proprieties  of  his 
social  station  and  profession,  going  about  his  parish  telling 
improper  stories,  and  not  conducting  himself  rightly  in  regard 
to  some  of  the  female  members  of  his  congregation.  On 
admission  to  the  Asylum,  his  mental  symptoms  were  those 
of  simple  coherent  "reasoning  mania."  He  had  stricture, 
copper-coloured  blotches  on  his  skin,  and  irregular  baldness. 
After  being  in  the  Asylum  for  a  month  he  affirmed  he  had 
several  "  fits,"  but  there  was  no  proof  then  of  convulsions. 
He  was  untruthful,  mahcious,  showed  no  natural  feeling 
and  no  self-respect.  He  was  a  year  in  this  Asylum,  was  then 
transferred  to  another,  and  then  back  to  this  where  he  died. 
His  mental  power  steadily  deteriorated;  he  became  subject 
to  regularly  recurring  convulsive  seizures ;  after  some  years 
he  had,  along  with  general  weakness,  a  partial  paralysis  of 
the  left  side,  with  incontinence  of  urine,  thickness  but  not 
tremulousness  of  speech.  Mentally  he  passed  from  irritability 
into  enfeeblement  and  loss  of  memory,  from  that  into  stupor, 
in  which  state  he  died,  thirteen  years  after  he  first  showed 
mental  symptoms,  and  twenty-five  years  after  he  had  con- 
tracted the  attack  of  syphilis  which  had  been  at  the  root  of 
all  his  ills. 

On  post-mortem  examination  the  calvarium  was  found  con- 
densed, and  the  right  side  of  the  frontal  bone  thicker  than 
the  left.  The  dura  mater  was  much  thickened,  congested,  and 
in  some  places  adherent  to  the  bone  and  to  the  pia  mater,  and 
this  last  to  the  brain  convolutions,  so  that  the  dura  mater  could 
not  be  removed  without  lacerating  the  convolutions.  This  was 
particularly  the  case  over  the  parietal  and  frontal  lobes.  On 
section  a  great  part  of  the  centre  of  the  anterior  lobe  of  the 
right  hemisphere,  and  many  of  its  convolutions,  were  found  to 


470  SYPHILITIC    INSANITY, 

be  atrophied,  the  place  of  the  neurine,  Avhite  and  grey,  being 
taken  by  a  flocculent  gelatinous  fibrous  material.  The  outer 
layer  of  the  grey  matter  of  those  convolutions  was  found  to 
be  normal  looking,  like  the  appearances  in  Plate  AT^I,  but 
not  so  advanced.  On  the  left  side  of  the  brain  the  white 
matter  was  generally  lacking  in  consistence — pale  in  some 
places  and  congested  in  others.  The  lining  membranes  of  all 
the  ventricles  were  very  granular.  The  basal  ganglia  on  the 
right  side  were  softened  and  congested  in  spots. 

An  examination  of  the  arteries  of  the  brain  showed  a 
hypertrophy  of  all  the  coats,  causing  obHterations  of  the  lumen 
in  places,  irregular  contractions,  and  nodulated  thickenings 
(Plate  I.  fig,  4).  Every  form  of  irregular  local  arteritis  was 
found,  all  the  vessels  being  more  or  less  affected,  but  especially 
the  branches  of  the  middle  and  anterior  cerebral  passing  to 
the  atrophied  part  of  the  right  hemisphere. 

The  spinal  cord  was  found  to  have  undergone  general 
atrophy,  with  anaemic  and  softened  portions  in  the  dorsal 
region,  and  intensely  congested  portions  in  the  lumbar  region. 
The  dura  mater,  pia  mater,  arachnoid,  and  cord  were  all  matted 
together  in  some  places.  The  liver  was  found  to  be  puckered 
"with  cicatrices,  and  to  have  a  small  giunmatous  tumoui  the 
size  of  a  bean  in  one  portion  of  it. 

It  was  evident  that  here  there  had  been  a  syphilitic  inflam- 
mation of  the  membranes ;  but  the  great  bulk  of  the  mental 
and  bodily  symptoms  could  be  traced  to  the  effects  of  the 
arteritis,  which  had  caused,  first,  irritation  in  the  brain  con- 
volutions and  then  a  slow  process  of  blood  starvation.  The 
real  character  of  the  case  was  never  diagnosed  during  life. 

In  the  following  case  the  arteritis  seems  to  have  ceased  to 
progress  at  a  very  early  period  of  the  disease,  and  its  effects, 
mental  and  bodily,  icere  therefore  ahnost  stationary  for  thirty- 
five  years  : — H,  S,,^  aet.   30  on  admission.      Patient   had   a 

1  This  case  was  more  fully  reported  by  the  late  Dr  J.  J.  Brown,  then 
assistant  phj-sician,  Royal  Edinburgh  Asylum,  in  the  Journal  of  MeiUal 
Science,  July  1875. 


SYPHILITIC   INSANITY.  471 

severe  attack  of  sypliilis  at  17,  for  wliich  lie  was  treated  witli 
mercury.  After  this  lie  was  always  irritable,  and  sometimes 
violent.  On  one  occasion  lie  attacked  his  mother,  and  smashed 
the  door  of  a  neighbour's  house  with  a  poker,  and,  when  taken 
to  the  police  office  that  night,  had  a  partial  hemiplegic  attack. 
He  was  for  ten  years  in  a  private  asylum  at  Musselburgh,  and 
then  Avas  taken  to  Morningside.  On  admission  he  had  delu- 
sions of  suspicion,  impulsiveness,  violence,  and  also  hallucina- 
tions of  hearing,  fancying  he  heard  voices  calling  him  "low," 
"mean,"  and  seeing  figures  that  he  imagined  jumped  down 
his  throat.     He  was  taciturn  and  melancholic  too. 

In  three  years  his  delusions  were  worse.  He  seemed  to 
have  had  a  slight  difficulty  of  speech,  and  he  imagined  a 
woman  had  located  herself  in  his  mouth  and  was  the  cause  of 
this,  as  well  as  of  a  bitter  taste  in  his  mouth.  His  gait  was  a 
little  unsteady,  straddling,  and  ataxic,  and  he  dragged  one  leg 
a  little.  His  bodily  condition  was  never  strong,  he  looked 
weary  and  pale,  and  he  always  suffered  more  or  less  from 
dyspepsia.  His  delusions,  impulsiveness,  and  excessive  irrita- 
bility of  temper  continued  for  the  twenty -six  years  he  lived  in 
the  Asylum ;  and  superadded  to  these  there  was  considerable 
general  enfeeblement  of  mind.  His  legs  got  weaker  before 
death  in  1875.  He  died  of  diarrhoea.  The  brain  membranes 
were  thickened,  a  thin  layer  of  blood-clot  was  found  under 
the  pia  mater,  and  the  convolutions  were  much  atrophied. 
There  was  a  small  cyst  in  the  pons,  evidently  from  old 
apoplexy.  The  microscopic  appearances  were  very  striking 
(see  Plate  I.  fig.  4).  The  arteries  in  the  pons  were 
thickened,  the  muscular  coats  being  hypertrophied  to  an 
enormous  extent,  the  outer  coat  being  also  much  thickened, 
and  in  and  around  this  coat  was  a  molecular  deposit 
containing  also  granular  masses,  this  deposit  in  many  in- 
stances fiUing  up  the  perivascular  space.  At  some  parts  the 
vessels  were  patent,  at  others  completely  occluded  and  the 
lumen  absent,  the  artery  presenting  the  appearance  of  con- 
centric rings  in  the  centre  of  a  granular  deposit.     The  grey 


472  SYPHILITIC   INSANITY. 

matter  of  the  convolutions  was  found  to  be  degenerated,  the 
cells  being  atrophied,  and  their  spaces  in  many  instances  being 
occupied  by  a  few  granules  (Kke  those  shown  in  Plate  XIII. 
fig.  6).  The  spinal  cord  was  also  affected  in  the  same  way  in  its 
arteries,  and  in  its  grey  and  white  substance.  There  were  many 
microscopic  apoplexies  in  the  white  substance  of  the  cord. 

Xo  better  demonstration  of  chronic  vascular  disease  of 
syphilitic  origin,  and  its  effects  of  brain  starvation,  degenera- 
tion, and  atrophy,  with  the  resulting  mental  suspicions, 
hallucinations  of  hearing,  and  lack  of  self-control,  could  have 
been  afforded  than  this  case. 

Death  of  the  White  Substance  loith  Survival  of  the  Grey. — 
I  have  seen  some  of  the  most  extraordinary  pathological 
effects  in  the  brain  from  slow  syphilitic  arteritis.  I  have 
several  specimens  of  brains  in  which  the  whole  of  the  white 
substance  in  the  inside  of  the  anterior  and  middle  lobes, 
lying  between  the  outside  convolutions  and  the  central 
ganglia,  had  gradually  and  entirely  disappeared,  leaving  a 
vacant  space  filled  with  fluid  and  a  few  fibrous  flocculi.  The 
grey  substance  of  the  convolutions,  looked  at  from  the  inside 
in  an  antero-posterior  section  of  a  hemisphere,  presents  the 
most  extraordinarily  defined  appearance,  just  as  much  so  as 
when  looked  at  from  the  outside  (see  Plate  YII.).  They 
looked  as  if  the  white  substance  had  been  carefully  pared  off 
them,  leaving  the  grey  matter  intact.  The  effect  Avas  exactly 
what  would  have  resulted  had  that  portion  of  brain  been 
steeped  in  a  fluid  which  had  the  power  of  dissolving  away 
the  white  substance  and  leaving  the  grey  entire.  The  cause 
of  this  is  no  doubt  the  histological  facts  that — (1)  the  grey 
substance  of  the  convolutions  has  five  times  the  amount  of 
capillary  blood  supply  of  the  white ;  and  (2)  the  source  and 
mode  of  supply  are  different,  the  grey  substance  getting  it  from 
the  already  divided  and  anastomosing  network  forming  the 
pia  mater,  and  the  white  substance  getting  its  supply  from 
single  vessels,  which  in  dividing  form  only  an  infrequent 
anastomosis,  and  a  network  with   large   long   meshes.     The 


SYPHILITIC   INSANITY.  473 

wliite  substance,  in  fact,  dies,  and  disappears  through  an 
arteritis  which  only  causes  partial  atrophy,  anaemia,  and 
lessened  mental  function  in  the  grey  convolutions.  Looking 
at  such  a  brain,  many  questions  suggest  themselves.  How  do 
the  convolutions  act  whose  white  fibres  of  communication  in- 
Avards  and  their  inter-convolutional  fibres  have  quite  disap- 
peared ?  Why  do  they  not  undergo  degeneration  ?  Is  there 
a  general  power  of  conduction  in  the  convolutions  from  one 
through  the  next,  and  so  on  till  it  reaches  one  whose  ingoing 
fibres  are  intact  ?  Can  the  convolutions  still  act  in  some 
degree  even  when  deprived  of  their  projection  and  association 
systems  of  white  fibres  ? 

Most  of  the  vascular  cases  have  the  general  course  of  H.  E. 
Mentally  a  change  of  character,  morbid  suspicions,  loss  of 
self-control  and  of  the  moral  feelings,  a  disregard  of  the 
decencies  of  life,  then  an  intense  irritability,  often  with 
violence  and  a  loss  of  memory,  then  an  enfeeblement  of  the 
mental  power,  ending  in  dementia.  Bodily,  an  unhealthy 
and  cachectic  general  state,  a  lack  of  trophic  power, 
with  no  cephalalgia  necessarily,  then  a  general  failure  of 
muscular  power  and  a  tendency  to  partial  paralysis,  then 
occasional  epileptiform  fits,  sometimes  unilateral,  but  never 
more  localised  than  a  motor  paralysis  that  advances  and 
recedes  in  a  puzzling  way,  then  loss  of  power  over  the 
sphincters,  loss  of  trophic  power,  and  death,  if  that  does  not 
occur  at  a  previous  stage  through  an  attack  of  convulsions. 
The  duration  is  very  different  in  different  cases,  but  in  my 
experience  it  is  never  less  than  ■  five  years,  and  may  be 
twenty-five.  If  one  was  fortunate  enough  to  be  able  to 
diagnose  a  case  in  the  earliest  stages,  no  doubt  the  iodide 
of  potassium,  with  mercury,  nerve  tonics,  nutrients,  and  brain 
rest,  should  be  prescribed,  and  I  think  I  had  a  case  where 
those  measures  saved  the  patient  from  going  further  than 
mild  and  manageable  childishness,  without  tendency  to 
convulsion.  But  if  the  lumen  of  an  artery  has  been  lessened 
by  slow  syphilitic  arteritis,  we  have  little  reason  to  think  it 


474  SYPHILITIC   INSANITY. 

can,  by  any  therapeutic  means,  be  made  more  patent ;  and  if 
some  of  the  brain  tissue  has  already  been  starved  into  atrophy, 
most  certainly  it  would  be  a  groundless  hopefulness  to  think 
of  its  possible  restoration. 

Looked  at  purely  from  the  pathological  point  of  view,  the 
arteritis  may  aft'ect  vessels  of  any  and  every  size  down  to 
capillaries,  may  be  inside  (endarteritis)  or  outside  (periarteritis) 
of  the  arterial  wall.  It  is  usually  irregular  and  local,  and  often 
nodular.  I  do  not  know  any  more  instructive  demonstration 
of  the  visible  effects  of  a  lack  of  blood  supply  to  brain  cells 
and  fibres  than  may  be  found  in  sections  from  different  parts 
of  a  brain  affected  by  syphilitic  arteritis. 

Syphilomatous  Insanity. — The  fourth  or  syphilomatousform  is 
so  exceedingly  various  in  its  symptoms,  mental  and  bodily,  that 
I  really  do  not  know  where  to  begin.  It  may  consist  of  a  syphi- 
litic meningitis  attended  with  general  convulsions,  a  temporary 
stupor  and  delirium,  which  is  very  curable  by  the  iodide  of  potas- 
sium. Or  it  may  consist  of  a  quick -growing  syphiloma  within 
a  convolution,  that  causes  in  a  few  weeks  extensive  softening, 
wild  maniacal  excitement,  general  convulsions  and  paralysis, 
and  speedy  death,  the  whole  process  being  from  the  beginning 
absolutely  beyond  the  reach  of  cure,  or  even  of  alleviation. 
Or  it  may  consist  of  local  gummata,  causing  pressure,  local 
convulsions,  mental  irritabihty,  and  very  slowly  progressive 
dementia.  Or  it  may  consist  of  great  cakes  of  syphilitic 
inflammation  and  gummatous  or  semipurulent  deposit  over 
one  or  both  hemispheres,  causing  gradual  dementia,  and 
at  last  coma.  Or  it  may  be  a  membranous  or  bony  tertiary 
lesion  that  has  been  quite  arrested  in  its  growth,  but  has 
set  up  what  is  practically  epilepsy  and  ordinary  epileptic 
insanity.  I  shall  just  give  an  idea  of  the  disease  by  referring 
to  a  few  cases.  I  shall  first  illustrate  the  more  acute  forms 
by  the  following  case  of  syphilitic  tumour  of  rapid  groioth 
■within  the  substance  of  the  brain. 

H,  T.,  set.  26,  a  prostitute,  whose  history  was  not  knoAvn 
except  that  she  had  been  deliriously  maniacal,  ceplialalgic,  and 


SYPHILITIC   INSANITY.  475 

had  taken  convulsive  attacks.  On  admission  to  the  Asylum 
she  was  vacuous  and  taciturn,  and  almost  in  a  condition  of 
stupor.  Her  pupils  were  unequal,  but  there  was  no  motor 
paralysis  visible.  She  partly  wakened  up,  and  spoke  in  a 
slow,  hesitating  way.  After  being  in  the  Asylum  for  a 
month,  and  taking  many  convulsive  attacks  during  that  time, 
she  died  suddenly  one  day  after  such  an  attack.  A  small 
gummatous  tumour  was  found  in  the  centre  of  the  anterior 
lobe  of  the  right  side,  involving  one  of  the  frontal  convolu- 
tions, and  this  was  surrounded  by  a  great  ring  of  white 
softening  and  brain  anaemia,  and  that  again  by  an  outer  ring 
of  congestion.  I  had  lately  another  case  very  similar  to  this, 
H.  U.,  set.  41,  with  no  ascertainable  history  of  syphilis,  but 
who  had  had  several  miscarriages.  Uncle  had  been  a 
patient  in  the  Asylum.  For  a  year  she  had  suffered  from 
intense  cephalalgia,  mostly  on  the  right  side,  passing  to  the 
forehead  and  affecting  her  sight.  For  six  months  she  had 
had  fainting  turns,  and  for  three  weeks  convulsive  attacks. 
On  admission  she  was  mentally  confused,  complained  of 
voices  round  her  bed,  and  talked  wildly  and  incoherently 
about  things  that  had  no  connection  with  the  questions  asked 
her.  She  began  to  take  convulsions  a  fortnight  after  admis- 
sion, and  died  of  these  in  three  weeks.  I  had  during  life 
diagnosed  brain  tumour,  probably  syphilitic.  After  death 
we  found  under  the  dura  mater  several  hsemorrhagic  patches. 
The  convolutions  presented  a  flattened  "  glazed  "  appearance. 
Section  of  the  brain  showed  great  pallor  of  the  white  sub- 
stance of  the  left  hemisphere.  In  the  lower  and  middle  part 
of  the  left  internal  capsule  there  were  two  small  gummatous 
tumours,  one  the  size  of  a  big  bean,  the  other  the  size  of 
a  filbert.  They  were  surrounded  by  an  area  of  loose,  dis- 
organised, softened  brain  substance,  involving  the  anterior 
third  of  the  corpus  striatum,  spreading  through  the  temporo- 
sphenoidal  lobe,  the  whole  of  which  was  pulpy.  The  soften- 
ing extended  also  along  the  posterior  horn  of  the  lateral 
ventricle.      In    the    right    hemisphere    there    was    also    an 


476  SYPHILITIC   mSAXITY. 

abnormal  pallor,  but  there  was  no  softening  except  in  the 
posterior  lateral  ventricle,  wliicli  presented  much  the  same 
appearance  in  a  less  degree  as  on  the  left  side.  There  was 
no  tumour  or  deposit  on  the  right  side. 

This  exemplified  what  is  very  commonly  found  in  the 
brain,  viz.,  a  si/mmetrical  lesion  in  exactly  the  same  place  on 
both  sides  of  the  brain.  My  experience  is  that  vascular  and 
trophic  lesions  of  the  brain,  such  as  apoplexies,  large  or 
capillary  softenings,  and  thrombosis,  are  exceedingly  apt 
to  occur  in  both  hemispheres  in  the  same  places  and  almost 
at  the  same  time.  This  vascular  and  tropJio-organic  sympathy 
of  the  two  hemisjoheres,  extending  to  diseased  conditiojis,  is  a  . 
viost  important  fact  little  noticed  in  pathological  luorks,  but 
physiologically  and  pathologically  it  must  ever  he  kept  in  mind 
in  brain  study. 

In  both  the  above  cases  the  cerebral  blood-vessels  seemed 
normal.  A  small  local  quick-growing  syphiloma  in  the  brain 
substance  had  caused  surrounding  destruction  by  pressure  and 
irritation,  setting  up  an  inflammatory  process,  and  causing 
tissue  death.  The  symptoms  had  been  cephalalgia,  convul- 
sions, mania,  confusion,  loss  of  attention  and  memory,  and 
sudden  death  within  a  short  time.  I  have  since  met  with 
two  cases  of  the  same  kind  of  much  slower  course  and 
without  convulsions. 

The  next  example  I  shall  tcike  of  brain  syphilis  is  one  that 
most  physicians  would  not  be  inclined  to  regard  as  one  of 
"  insanity  "  at  all,  though,  as  a  matter  of  fact,  the  patient  was 
incapacitated  for  loork,  confused  and  stupid  in  mind  and  at 
times  delirious.  But,  being  a  clear  case  of  brain  syphilis  of  a 
common  type,  idth  mentcd  symptoms  cured  at  home  by  appro- 
priate treatment,  it  is  more  important  to  the  practising  physician 
thcvn  cases  tcith  more  decided  mental  symptoms. 

H.  Y.,  £et.  33.  Patient's  mother  had  been  insane  for  a  year, 
"after  a  fall  on  the  head."  He  had  syphilis  six  or  seven 
years  ago,  with  few  secondary  symptoms.  He  had  not  been 
feeling  well  for  six  or  seven  weeks,  sufferuig  from  very  severe 


SYPHILITIC   INSANITY.  477 

headaches.     Three  weeks  ago  he  took  suddenly  a  very  severe 
attack. of  general  convulsions  with  unconsciousness.     Before 
that  he'  had  on  several  occasions  a  rather  pleasant  momentary 
feeling  of  "being  in  a  trance,"  and  this  sensation  preceded  the 
fit.     When^  taken  home  after  the  fit,  he  was  confused  and 
had  severe  cephalalgia,  and  had  slight  left  hemiparesis.     He 
went  to  the  late  Dr  Begbie,  who  prescribed  iodide  of  potassium 
in  5-grain  doses.     Since  then  he  had  travelled  about  a  little, 
and  tried  to  do  business,  but  could  not  do  so  properly  on 
account  of  loss  of  memory,  lack  of  power  of  attention,  general 
confusion  of  mind,  and  severe  cephalalgia.     When  I  first  saw 
liim  he  was  considerably  paralysed  in  the  left  side;  he  had 
double  vision,   and  a  loud  noise   in  his  right   ear;    he   was 
confused,  mentally  depressed,  his  memory  very  poor ;  he  was 
irritable,  wayward,   tending   to  be  violent,  and   difficult   to 
manage.     If  he  had  been  a  poor  man  he  would  probably  have 
been  sent  to  an  asylum  at  once.     He  sufi'ered  the  most  fearful 
cephalalgia,  especially  at  night,  and  the  slighest  tap,  especially 
over  the  right  side  of  his  brow,  greatly  increased  his  sufferings. 
The  skin  of  the  right  side  of  his  head  and  face  was  hyperses- 
thetic,  and  his  right  conjunctiva  injected.     He  could  not  read 
nor  write.     Pulse,  80;  temperature,  98"4°.     Appetite   gone, 
tongue  much  furred.     I  put  him  at  once  on  10-grain  doses  of 
the  iodide  of  potassium,  with  15  grains  of  the  bromide,  and 
Jg-th  of  a  grain  of  the  bichloride  of   mercury  thrice  a  day, 
with  milk  and  potass-water  alone  for  diet.     For  about  a  week 
he  got  no  better,  suffering  the  most  fearful  agony  in  his  head 
at  night,  becoming  delirious,  and  wanting  to  go  out  at  the 
window.     I  tried  chloral  in  25-grain  doses  repeated  every 
two  hours,  as  well  as  the  bromides  and  tincture  of  cannabis 
indica,  in  large  and  repeated  doses,  to  dull  the  night  pain  and 
procure  sleep,  but  with  only  very  temporary  relief.     In  the 
mornings,  after  those  medicines,  he  was  always  more  confused 
and  irritable,  and  had  no  appetite.     By  far  the  best  thing  I 
found  for  easing  the  night  cephalalgia  and  procuring  sleep  was 
to  make  him  lay  his  head  on  a  rubber  bag  of  almost  unbear- 


478  SYPHILITIC   INSANITY. 

ably  hot  Tvater.  After  a  week  the  cephalalgia  abated,  he  got 
a  little  more  sleep,  and  he  became  less  irritable  and  confused 
and  less  frequently  dehrious,  and  he  looked  better,  but  the 
paralysis  did  not  improve  for  a  fortnight,  and  then  I  raised  the 
dose  of  the  iodide  to  15  grains  three  times  a  day.  In  three 
weeks  the  double  vision  ceased,  and  he  began  to  walk  and 
grasp  better.  The  cephalalgia  became  nearly  paroxysmal,  and 
took  the  form  of  neuralgia  of  the  supraorbital  branches  of  the 
fifth  nerve.  He  became  less  sensitive  to  tapping  his  head,  his 
tongue  got  clean,  and  his  appetite  so  ravenous  that  I  had 
much  difficulty  in  keeping  him  from  eating  flesh  diet.  In  a 
month  he  was  still  further  improved,  could  walk,  read,  and 
dictate  a  httle,  and  was  able  to  be  out  in  the  open  air,  though 
any  exertion,  mental  or  physical,  produced  a  sense  of  intense 
exhaustion.  The  noise  he  had  in  his  right  ear  disappeared 
about  that  time,  and  also  a  feeling  of  cold  on  that  side  of  the 
face.  In  five  weeks  he  was  almost  convalescent,  and  mentally 
normal,  though  he  had  on  two  occasions  the  "  trance  "  feeling 
that  preceded  the  convulsions.  In  two  months  he  had  what 
was  evidently  a  syphihtic  inflammation  of  the  periosteum  over 
the  mastoid  process  of  the  right  temporal  bone.  He  omitted 
the  iodide  for  a  week  at  my  advice,  but  at  once  he  began 
to  feel  worse  in  all  respects  mentally  and  bodily,  I  then 
increased  the  dose  to  20  grains  three  times  a  day.  This  he 
took  steadily  for  two  years  without  showing  a  trace  of  iodism ; 
on  the  contrary,  getting  fat  and  strong,  and  mentally  vigorous. 
A  dimness  of  vision  in  the  left  eye,  and  a  tendency  to  pains 
and  shght  weakness  in  his  left  side  on  damp  days,  were  the 
last  of  the  symptoms  to  disappear.  After  two  years  I  finally 
stopped  the  iodide,  after  having  several  times  tried  to  do  so 
before  with  bad  results,  and  he  keeps  well  and  fit  for  business, 
with  just  a  trace  of  head  symptoms  at  times. 

This  was  no  doubt  a  case  of  syphilitic  inflammation  and 
thickening  of  the  membranes  of  the  brain  over  the  right 
hemisphere,  afi"ecting  the  cortex  of  the  organ  and  its  functions 
mental  and  bodily  by  pressure  and  inflammatory  irritation. 


ALCOHOLIC   INSANITY.  479 

There  was  no  doubt  a  gummatous  deposit  there.  The  bene- 
ficial effects  of  large  doses  of  the  iodide,  and  the  tolerance  of 
thosie  d'oses  for  so  long  after  the  symptoms  had  apparently 
disappeared,  is  the  common  experience  in  those  cases.  The 
mental  symptoms  were  characteristic  in  all  respects.  I  have 
had  other  cases  of  this  kind,  not  put  under  treatment  so  soon, 
which  have  gone  on  for  years  partially  paralysed,  subject  to 
the  convulsions,  and  at  last  dying. 

Frequency. — Out  of  3145  cases  of  insanity  of  all  classes  of 
society  admitted  into  the  Eoyal  Edinburgh  Asylum  during 
the  past  nine  years,  16  have  been  cases  of  syphilitic  insanity, 
or  about  ^  per  cent.  Few  of  these  recovered,  or  are  likely  to 
recover,  the  majority  of  the  patients  being  far  advanced  in 
their  disease  before  admission,  with  serious  involvement  of  the 
structure  of  the  brain. 


ALCOHOLIC  INSANITY. 

Alcohol  as  a  cause  of  insanity  ;  over  20  per  cent.  ;  as  a  cause  of  human 
degeneration — Beal  Alcoholic  Insanity  :  Five  fornas — 1.  Delirium 
tremens  often  has  a  preliminary  stage  of  suicidal  and  homicidal 
impulse  ;  importance  of  this  ;  often  leaves,  after  many  attacks,  an 
insanity  with  hallucinations  of  hearing  and  morbid  suspicions  ; 
treatment.  2.  Chronic  alcoholism :  Motor  symptoms  ;  suspicions  ; 
hallucinations ;  impulsiveness ;  dangers  ;  reflex  function  of  cord 
commonly  abolished  ;  likeness  of  speech  to  general  paralj'sis  ;  sus- 
picions of  poisoning ;  tends  to  end  in  dementia  or  delusional 
insanity ;  first  attacks  curable ;  treatment.  3.  Mania  a  Potu : 
Symptoms  ;  acute  delirious  mania  ;  duration  short ;  kind  of  brain 
in  which  this  occurs  ;  general  want  of  control ;  hereditary  pre- 
disposition. 4.  Alcoholic  dementia :  The  end  of  many  chronic 
drinkers  ;  likeness  in  symptoms  and  pathology  to  ordinary  second- 
ary dementia  after  mania.  5.  Dipsomania :  A  psychokinesia  ; 
diagnosis  ;  prognosis,  bad  ;  treatment,  an  island  where  whisky  is 
unknown,  work,  supervision,  redevelop  the  conscience  ;  hereditary 
connections.  Impure  alcoholic  drinks  are  most  apt  to  cause 
alcoholic  insanity.  Pathological  appearances  found  in  brains  of 
drunkards  like  those  found  among  the  insane. 


480  ALCOHOLIC  INSANITY. 

Different  Relationships  of  Alcoliol  to  Insanity. — -I  do  not 
speak  here  of  the  use  of  alcohol  as  a  general  cause  of  all 
kinds  of  insanity.  It  is  unfortunately  the  most  common  of 
all  the  causes  of  the  disease,  in  some  cases  producing  it  de 
novo,  in  others  bringing  into  activity  hereditary  and  acquired 
brain  weaknesses.  From  15  to  20  per  cent,  of  the  cases  of 
mental  disease  may,  taking  the  country  through,  be  put  down 
to  alcohol  as  a  cause,  wholly  or  in  part.  As  a  cause  of .  in- 
sanity it  is  not  followed  by  constant  results.  Conditions  of 
mental  depression,  of  exaltation,  of  enfeeblement,  of  stupor, 
of  morbid  impulsiveness,  may  all  be  caused  by  it.  General 
paralysis,  paralytic  insanity,  epileptic  insanity,  adolescent 
insanity,  climacteric  and  senile  insanities  may  be  due  to 
alcohol  as  exciting  causes  of  the  attacks.  When  so  caused, 
we  do  not  call  these  alcohoHc  insanity.  I  have  no  time  to 
speak  here  of  those  most  interesting  degenerations  of  indi- 
viduals and  of  races  that  follow  the  excessive  use  of  alcohol. 
Two  great  French  alienists.  Morel  ^  and  Moreau  de  Tours,- 
have  told  us  nearly  all  we  know  of  that  subject.  They 
looked  at  the  insanity  as  one  of  the  effects  of  evil  conditions 
of  hf e,  of  bad  and  insufficient  foods,  of  the  use  of  all  sorts  of 
neurotics  in  changing  for  the  worse  the  type  of  human  being 
in  the  first  and  in  succeeding  generations.  There  are  few  of 
the  unfavourable  conditions  of  hfe  that  by  themselves  cause 
more  human  degeneration  than  the  excessive  use  of  alcohol. 
■Many  of  the  American  Indian  tribes,  fine  races  to  begin 
with,  have  been  simply  killed  ofif  by  it  in  a  generation  or  two, 
degenerating  in  body  and  mind  all  the  time.  You  are  aware 
of  the  pathological  tissue  degenerations  that  are  caused  or 
promoted  by  it,  the  atheromatous,  the  fatty,  the  cirrhotic, 
changes  that  take  place  in  the  vascular,  the  renal,  the 
hepatic,  the  glandular,  the  fibrous,  and  the  nervous  tissues. 
Those  are  the  individual-tissue  and  single-organ  damages. 
The  whole  organism  suffers  somatic  and   mental   lowering, 

^  Traite  dcs  Deg6nerescences  de  VEspece  Humaine. 
^  La  Psyclwlogie  Morbide, 


ALCOHOLIC   INSANITY.  481 

alteration  of  function  and  of  energising.  Morbid  cravings 
for  alcohol,  or  diminished  self-control  in  regard  to  its  use,  or 
human-  degeneration  in  various  forms  are  transmitted  from 
generation  to  generation,  in  the  same  or  other  forms,  by  heredi- 
tary laws,  if  not  corrected  by  new  and  improved  conditions 
of  life.  In  some  individuals  they  are  mere  potentiahties  and 
tendencies,  in  others  they  have  assumed  definite  forms,  and 
become  insanity,  idiocy,  stuntedness  of  growth,  ugliness, 
deformity,  deaf-mutism,  sterility,  incapacity  for  high  kinds  of 
education,  and  immorality.  Those  are  large  general  questions, 
of  the  highest  interest  socially  and  physiologically.  They 
often  become  very  practical  questions  to  medical  men. 
Alcoholic  degenerations  influence  the  types  of  all  ordinary 
diseases,  and  they  interfere  much  with  the  treatment  adopted 
for  their  cure.  Wlien  our  profession  becomes,  as  it  should 
be,  and  as  I  have  no  doubt  it  will  in  time  become,  the 
guardian — by  prophylaxis — of  the  physical  and  mental  well- 
being  of  the  people,  and  the  high  priest  of  authority  for  the 
regulation  of  the  conditions  of  life,  such  questions  will  come 
far  more  to  the  front  than  they  are  at  present,  and  they  will 
then,  no  doubt,  form  an  important  part  of  medical  study. 

Forms  of  Alcoholic  Insanity. — Meantime  I  have  merely  to 
describe  and  illustrate  those  forms  of  mental  disease  in  which 
alcohol  has  not  only  been  the  cause,  but  has  so  influenced  the 
symptoms  that  they  are  in  some  way  special"  or  peculiar,  so 
that  the  mental  and  bodily  results  are  as  it  were  specific, 
and  may  be  called  alcoholic  insanity.  Few  agents  have  such 
different  results  on  difi'erent  brains  as  alcohol.  For  that 
reason  alcoholic  insanity  is  not  in  all  cases  of  the  same  kind. 
The  following  are  the  five  chief  forms  : — 1.  Acute  Alcoholism  ; 
2.  Chronic  Alcoholism ;  3.  Mania  a  Potu ;  4.  Dipsomania ; 
5.  Alcoholic  Mental  Degeneration. 

Acute  Alcoholism. — The  most  typical  alcoholic  insanity  is 
delirium  tremens,  or  acute  alcoholism.  That  this  is  described 
in  ordinary  text-books  on  general  medicine,  and  is  treated 
usually  at  home  or  in  general  hospitals,  and  is  of  short  dura- 

2  H 


482  ALCOHOLIC   INSANITY. 

tion,  does  not  make  it  the  less  a  true  insanity.  From  a 
symptomatological  point  of  view  it  is  a  typical  excited  or 
motor  melancholia,  characterised  especially  by  hallucinations 
of  sight,  fleeting  delusions  of  all  kinds,  but  especially  delusions 
of  suspicion,  depressed  and  suicidal  feelings,  partial  or 
complete  incoherence,  failure  of  memory,  impulsiveness, 
tendency  to  mistake  identities  ;  in  some  cases  by  unconscious- 
ness, and  by  loss  of  power  of  attention.  It  is  the  bodily 
symptoms  that  give  it  its  most  characteristic  features.  The 
motor  restlessness  and  the  motor  tremulousness  combined 
are  excessive  and  constant.  In  addition,  the  temperature  is 
usually  above  100°,  there  is  paralysis  of  the  appetite  for  food, 
often  sickness,  generally  lack  of  digestive  power  and  of 
assimilation,  a  rapid  loss  of  body-weight,  and  absolute  sleep- 
lessness. The  typical  cases,  and  in  fii-st  or  second  attacks, 
it  runs  a  somewhat  definite  course,  have  a  short  duration 
measured  by  days  or  weeks.  Such  cases  are  now  often 
certified  as  insane,  and  sent  to  asylums  for  treatment,  and  but 
for  the  ideas  connected  with  a  lunatic  asylum  they  are  often 
best  treated  there.  "We  have  the  means  of  treating  them 
more  satisfactorily  there,  according  to  the  present  ideas  of 
treatment,  than  in  an  hospital.  We  have  trained  attendants, 
suitable  rooms,  grounds  for  exercise  in  the  later  stages  of 
treatment,  and  no  necessity  for  the  use  of  narcotics  used 
merely  to  keep  the  patient  quiet  and  manageable.  The 
patients  often  recover  sooner  with,  us  than  in  hospitals,  chiefly 
because  we  can  keep  them  after  the  first  few  days  in  the  open 
air.  I  do  not  recommend  patients  sufi'ering  from  acute 
alcohohc  insanity  to  be  sent  to  asylums  if  they  have  money 
enough  to  have  good  skilled  attendance,  and  can  be  sent  to  a 
lodging  in  the  country  or  outskirts  of  a  town  after  the  first 
few  days,  simply  because  the  notion  of  having  been  in  a 
lunatic  asylum  is  repugnant  to  most  men's  feehngs,  and  it 
may  be  more  injurious  to  a  patient  afterwards  than  if  he  had 
been  treated  in  an  hospital  or  at  home.  It  would  be  easy 
enough  for  all  large  general  hospitals  to  have  some  rooms  and 


ALCOHOLIC  INSANITY.  483 

an  exercise  ground  for  the  treatment  of  such  cases.  The 
cliief  difficulty  is  the  expense  of  keeping  a  permanent  staff 
of  good 'trained  attendants  for  work  that  would  be  only 
occasional. 

Here  is  a  good  case  of  acute  alcoholism  sent  to  an  asylum,  J. 
A.,  set.  34.  Has  had  several  attacks  of  the  same  kind  before. 
Drinks  in  bouts,  not  steadily.  Is  of  an  excitable,  sensitive 
disposition  naturally.  Has  been  ill  for  about  a  week,  during 
which  he  has  not  slept.  Is  chattering  incoherent  nonsense, 
addressing  imaginary  persons  in  short  snatchy  semi-delirious 
sentences.  His  attention  cannot  be  roused  to  attend  to  the 
questions  put  to  him  ;  evidently  has  hallucinations  of  hearing 
and  of  sight.  He  looks  np  at  the  ceiling  and  round  the  walls 
as  if  following  some  object  with  his  eyes,  and  turns  and  says, 
"  Yes,"  "  What  is  it  ? "  &c.,  as  if  in  answer  to  questions  or 
remarks.  He  is  very  restless  and  tremulous,  so  that  he 
cannot  hold  a  cup  to  his  lips  and  drink  out  of  it  without 
spilling.  The  temperature  is  101°,  pulse  weak  and  quick,  skin 
perspiring,  eyes  sunk,  expression  of  face  haggard  and  almost 
vacant,  pupils  dilated  but  sensitive,  tongue  tremulous  and 
coated.  His  articulation  is  markedly  tremulous,  hke  that  of 
a  general  paralytic,  only  thicker.  The  reflexes  are  dull, 
and  the  spinal  reflex  action  almost  gone — in  this  last  respect 
differing  from  nineteen  out  of  twenty  general  paralytics.  His 
general  strength  is  very  low.  He  was  put  to  bed  and  fed 
with  milk  and  effervescing  potass- water,  alternated  with  beef- 
tea.  He  was  made  to  take  those  things  by  attendants,  con- 
trary to  his  inclination.  He  was  sent  out  to  walk  assisted  by 
an  attendant  for  an  hour  the  first  day,  and  that  night  he  was 
fed  every  hour  irrespectively  of  his  inchnation.  .  He  scarcely 
slept.  JS'ext  day  he  was  fed  regularly,  and  was  out  in  the 
open  air  most  of  the  day.  His  pulse  got  stronger  and  he 
slept  two  hours  that  night,  and  his  temperament  fell  to  100°. 
The  same  treatment  was  adopted  day  by  day,  and  no  medicine 
was  given  liim  but  quinine  and  nitro-muriatic  acid,  which 
were  prescribed  after  the  first  two  days.     In  four  days  he 


484  ALCOHOLIC   INSANITY. 

was  coherent  and  less  tremulous,  and  could  sit  still.  In  a 
"week  lie  was  rational,  and  in  ten  days  he  was  Avell,  all  hut  the 
sense  of  exhaustion. 

Rislis. — Some  cases  do  not  turn  out  so  well.  There  are  five 
chief  risks  from  the  alienist's  point  of  view  that  I  have  met 
with.  Th.Q  first  is  that  of  the  hrain  passing  into  a  condition 
of  stupor  and  coma,  with  sudden  death.  This  takes  place  in 
very  had  cases  that  have  soaked  and  lived  on  alcohol  for 
years.  I  once  had  a  great  stout  flahhy-looking  woman,  J.  B., 
whose  case  took  this  course,  and  she  died  in  ten  days.  She 
had  heen  dosed  with  opium,  and  had  had  alcoholic  convul- 
sions before  admission.  We  found  intense  hrain  congestion, 
thickening  of  the  membranes,  and  the  outer  layer  of  the  grey 
matter  of  the  convolutions  diseased  microscopically,  being  full 
of  proliferated  nuclei.  The  second  risk  is  the  persistence  of 
the  hallucinations  of  hearing  after  most  of  the  other  symptoms 
have  gone.  This  is  apt  to  occur  where  there  have  been  many 
previous  attacks  and  a  neurotic  heredity.  The  treatment  is 
exercise  in  the  open  air  and  mental  distraction  from  the 
morbid  fancies.  Most  of  them  will  soon  recover  m  a  month 
or  two.  The  third  risk  is  the  persistence  or  aggravation  of 
the  insane  suspicions  of  poisoning,  of  conspiracy,  or  of  being 
worked  on  by  electricity  and  unseen  agency.  In  fact,  the  case 
becomes  one  of  delusional  insanity.  This  is  very  common, 
especially  the  delusion  of  poisoning.  This  arises  out  of  a 
misinterpreted  sensation.  There  is  chronic  gastritis  or  in- 
digestion from  alcoholic  irritation  of  the  mucous  membrane 
of  the  stomach,  and  the  patient  attributes  his  bad  sensations 
to  poison.  I  had  one  man,  J.  C,  who  retained  for  years  the 
delusion  that  I  had  put  rats  inside  him,  but  he  recovered 
through  proper  regimen  and  abstinence.  Such  cases,  as  well 
as  those  with  the  persistent  hallucinations  of  hearing,  are 
frequently  very  suicidal,  and  need  care  and  watching  on  that 
account.  The  subject  of  the  danger  of  suicide  in  all  kinds  of 
alcohoHc  insanity  has  not  been  at  all  sufficiently  dwelt  on. 
I  beheve  that  more  suicides,  and  combined  suicides  and  homi- 


ALCOHOLIC  INSANITY.  485 

cideSj  result  in  this  country  from  alcoholism  in  its  early  stages 
than  from  any  other  cause  whatsoever.  The  foxirih  risk  is 
that  the  man's  brain  and  the  man  himself  get  out  of  the 
attack  with  the  finer  points  of  moral  character  and  feeling 
rubbed  off.  He  is  mentally  different  from  his  former  self, 
though  not  insane.  He  is  more  untruthful  and  unfeeling, 
coarser  in  the  grain,  more  lazy,  and  less  honourable.  His 
brain  has  undergone  an  organic  change  to  some  extent.  In- 
stead of  delicate  membranes,  they  are  milky  and  thickened ; 
instead  of  sound  brain  substance,  it  is  mixed  with  the  pro- 
liferated and  matted  lymph  connective  processes,  neuroglia 
and  adventitious  tissue.  The  fifth  risk  is  run  in  patients 
who  have  a  heredity  to  insanity,  and  who  have  frequently 
had  alcoholic  insanity.  Instead  of  the  attack  resolving 
itself  in  the  natural  way,  it  runs  into  an  attack  of  ordinary 
melanchoha  or  mania,  which  ends  in  dementia.  In  fact, 
there  are  a  few  cases  that  pass  into  dementia  at  once  out  of 
the  attack  of  acute  alcoholic  insanity,  or  even  without  this 
— a  dementia  characterised  chiefly  by  a  loss  of  memory,  a 
listlessness  and  inaction,  and  yet  a  coherence  and  apparent 
power  of  reasoning  not  seen  to  be  unreal  till  you  test  them. 
Such  cases  have  been  "  soakers  "  for  years.  I  have  one  such 
gentleman  now,  J.  D.,  who  once  had  a  powerful  intellectual 
brain,  well  stored  with  hterature  and  professional  knowledge. 
He  drank  steadily  for  over  twenty  years,  and  then  had  an 
attack  of  alcoholism,  with  symptoms  of  kidney  degeneration 
and  hepatic  cirrhosis.  He  now  talks  very  rationally,  dilates 
on  the  cruelty  of  his  living  in  an  asylum,  and  on  his  ruin  by 
being  kept  from  his  business.  He  has  no  delusions,  and  if 
you  give  him  the  cue  will  repeat  half  a  play  of  Shakespeare's, 
and  tell  you  all  that  occurred  to  him  twenty  years  ago ;  but 
when  you  ask  him  the  day  of  the  week,  or  what  he  had  for 
breakfast,  he  cannot  tell  you  in  the  least.  Wlien  I  say  to 
him — and  this  has  been  my  stock  answer  to  his  complaints  of 

improper  detention  for  ten  years — "  Well,  Mr ,  write 

to  the  commissioners  and  state  your  case,"  he  will  reply,  "I'll 


486  ALCOHOLIC   INSANITY. 

do  so  at  once ;  there  never  was  such  an  outrage  committed  on 
a  man  before."  Yet,  in  ten  years,  he  has  never  written  to 
the  commissioners,  though  a  lawyer.  He  wanders  lazily 
about  our  grounds,  of  which  he  has  the  parole,  day  by  day, 
and  is  always  happy  in  a  negative  way,  except  during  the 
few  minutes  he  dilates  to  me  on  the  frightful  cruelty  of  his 
being  in  an  asylum.  I  had  another  such  case  who  could  not, 
for  a  long  time,  remember  his  own  name.  His  brain  had  to 
be  re-educated  in  this  simple  act  of  memory.  Such  patients 
are  usually  fat  and  torpid  in  movement.  They  have  lost  the 
fine  lines  and  movements  of  facial  expression.  Their  affective 
nature  is  dulled  or  twisted.  They  often  lose  the  craving  for 
stimulants  in  this  state. 

Chronic  Alcoholism. — The  next  form  of  alcoholic  insanity 
is  that  condition  commonly  known  as  chronic  alcoholism. 
This  also  is  always  accom|)anied  by  motor  signs,  many  cases 
indeed  not  being  technically  "insane."  It  is  often  ushered 
in  by  alcoholic  convulsions.  A  long-continued,  steady  soaking 
in  alcohol  is,  I  believe,  much  more  damaging  to  the  brain  in 
its  mental,  motor,  and  trophic  functions  than  bouts  of  heavy 
drinking  with  intermissions  of  sobriety.  In  chronic  alco- 
holism, looked  at,  as  I  am  doing,  chiefly  from  the  mental  point 
of  view,  all  the  symptoms  are  less  acute  and  last  longer  than 
those  of  acute  alcoholic  insanity.  The  suspicions  and  fears 
of  the  latter  become  a  chronic  symptom,  the  delusions  are 
less  numerous  and  more  apt  to  become  fixed.  The  hallucina- 
tions of  sight  are  absent,  but  we  are  far  more  apt  to  have 
hallucinations  of  hearing.  There  are  morbid  suspicions  and 
loss  of  inhibitory  power,  and  therefore  tendencies  to  impulsive 
acts  and  even  to  homicide.  There  is  sleeplessness,  but  it  is  not 
so  absolute.  There  is  motor  inco-ordination,  but  not  so  much 
restlessness.  The  speech  is  thick  and  often  tremulous ;  the 
tongue  very  quivering  and  inco-ordinated  in  its  movements. 
The  functions  of  the  cord  are  afi'ected,  causing  a  shghtly  ataxic 
walk,  and  an  abolition  of  the  spinal  reflexes,  and  sometimes  of 
the  tendon  reflex.     There  is  often  peripheral  neuritis.     The 


ALCOHOLIC  INSANITY.  487 

temperature  is  often  normal,  and  seldom  over  99°.  The 
appetite  is  never  keen,  and  the  taste  often  perverted,  so  that 
the  patient  complains  of  food  not  being  what  it  professes 
to  be. 

Here  is  a  typical  case,  J.  E.,  set.  41,  an  innkeeper,  whose 
brother  committed  suicide,  and  who  has  drank  hard  for  many- 
years — whisky  being  his  liquor.  His  present  attack  began 
by  sleeplessness,  restlessness,  insane  suspicions,  and  hallucina- 
tions of  hearing.  He  thought  his  wife  poisoned  his  food,  and 
kept  men  in  the  house,  whom  he  would .  go  and  seek  at  all 
hours  of  the  day  and  night  in  cupboards.  Wlien  sent  to 
the  Asylum — he  attempted  suicide  on  the  way — he  was 
almost  sleepless,  heard  voices  all  about  him  saying  he  was 
to  be  destroyed  and  punished,  and  the  voices  of  his  wife  and 
family.  His  temperature  was  98°.  He  was  tremulous  and 
shaky,  and  could  not  walk  far.  He  could  not  write,  or 
drink  out  of  a  tumbler  without  spilling  the  contents  on  the 
floor.  His  tongue  was  foul  and  very  tremulous — he  could 
scarcely  put  it  out  at  all.  His  appetite  was  gone,  and  he 
affirmed  the  meat  we  gave  him  was  the  flesh  of  his  children. 
He  was  put  on  the  bromide  of  potassium  and  steel,  was  fed 
with  liquid  custards,  which  contained  six  pints  of  milk  and 
ten  eggs  a  day  in  addition  to  some  solid  food.  He  was 
taken  out  to  walk  in  the  open  air  till  he  was  tired  three  times 
a  day,  and  he  had  a  constant  attendant  by  day  and  night 
to  prevent  him  doing  any  harm  to  himself  or  others.  Several 
times,  without  any  warning  and  with  no  provocation,  he  has 
rushed  at  and  broken  windows,  struck  attendants,  upset 
tables  covered  with  dishes,  and  jumped  into  our  pond.  He 
never  could  tell  after  doing  them  why  he  did  these  things. 
After  three  months'  treatment  he  was  scarcely  any  better. 
He  would  not  read,  or  play  games,  or  take  any  interest  in 
anything,  or  speak  to  any  one  except  when  spoken  to.  But 
in  six  months  he  is  now  much  improved,  and  showing  signs 
of  recovery,  which  I  do  not,  however,  expect  to  be  perfect. 

In   such  cases   recovery  is  slow,  and   is  very  apt   to   be 


488  ALCOHOLIC  INSANITY. 

incomplete,  if  it  occurs  at  all.  A  chronic  degeneration  of 
the  whole  of  the  train  plasma  has  begun.  The  intellectual 
power,  the  power  of  application,  origination,  and  independent 
energising  are  weakened,  the  delusions  of  suspicion  are  apt  to 
persist,  the  morals  and  self-respect  are  apt  not  to  be  regained, 
lying,  stealing,  and  cowardice  are  indulged  in.  The  afifection 
for  wife  and  cliildren  is  impaired.  Those  symptoms  run  on 
for  a  year  or  two,  and  then  we  have  dementia  supervening. 
But  this  termination  is  not  invariable.  First  attacks  are 
often  recovered  from  in  a  way,  even  second  attacks  will  be 
got  over,  but  third  and  fourth  attacks  seldom  completely. 
Instead  of  dementia,  we  have  sometimes  in  young  subjects 
delusional  insanity  supervening.  I  have  one  such  man,  with 
a  tremulous  tongue  that  he  always  puts  out  to  one  side,  who 
affirms  he  is  "  worked  only  by  electricity,"  and  hears  voices  ; 
another  who  says  his  food  is  poisoned ;  another  who  thinks 
every  one  near  him  insults  him  in  everything  they  do ; 
another  whose  ribs  are  broken  every  night  by  unseen  enemies. 
All  these  delusions,  you  see,  are  misinterpreted  sensations, 
no  doubt  of  cortical  origin. 

Treatment. — The  treatment  of  such  cases  consists  in  the 
use  of  tonics  of  all  sorts,  of  nerve  stimulants  such  as 
strychnine,  and  the  continued  current  for  a  time  if  such 
brain  stimulation  does  not  cause  excitement,  and  especially 
of  rigid  abstinence  from  alcohohc  stimulants,  and  the  leading 
of  a  controlled,  regular,  physiological  hfe  in  the  open  air, 
with  garden  work  if  possible. 

Mania  a  Potu. — There  is  a  third  kind  of  alcoholic  insanity 
of  short  duration,  but  great  acuteness  while  it  lasts,  called 
variously  mania  a  potu,  or,  very  expressively,  delirium 
ehriosum.  It  occurs  in  the  cases  of  persons,  often  young, 
with  unstable  brains  hereditarily.  It  needs  very  httle  drink 
to  produce  it;  and  in  many  cases  looks  hke  a  prolongation 
and  exaggeration  of  that  A\aLd  drunkenness  that  occurs  in 
certain  people  who  are  said  not  to  "  carry  their  hquor  weU," 
A  few  glasses  of  spirits  make  them  riotous  and  unmanageable, 


ALCOHOLIC   INSANITY.  489 

and  often  quite  delirious,  unconscious,  homicidal,  and  violent. 
Such  brains  have  often  shown  a  weakness  from  the  beginning, 
such'  as  lack  of  self-control,  tendencies  to  be  easily  led  away 
into  vice,  incapacity  for  getting  on.  In  some  of  them  there 
exists  a  craving  for  stimulants,  constituting  the  condition 
known  as  dipsomania.  Mr  Hayes  ISTewington,  while  one  of 
the  assistant  physicians  here,  gave  a  capital  account  of  mania 
a  potu,  with  cKnical  illustrations. 

Dipsomania. — I  have  already  treated  of  this  condition  in 
the  lecture  on  conditions  of  defective  inhibition  (p.  359). 

Alcoholic  Dementia  and  Degeneration.  —  Lastly,  I  shall 
simply  refer  to  the  lowered  mental  condition  that  is  apt  to 
result  from  the  too  great  indulgence  in  alcohol,  apart  from 
acute  insanity,  or  from  an  inordinate  craving,  or  even  from 
the  notion  of  disease,  bodily  or  mental,  at  all.  A  doctor  of 
experience  soon  comes  to  observe  in  his  patients  and  in  hi^ 
acquaintances  a  certain  kind  of  change,  mental,  moral,  and 
bodily,  in  some  of  the  people  who  habitually  "take  more  than 
is  good  for  them."  The  expression  of  face  and  eyes  you  see 
to  change,  the  mental  tone  to  be  lowered,  the  power  of  appH- 
cation  to  be  lessened,  the  self-control  to  be  weakened.  I  am 
safe  in  saying  that  no  man  indulges  for  ten  years  continuously 
in  more  alcohol  than  is  good  for  him,  even  though  he  was  never 
drunk  all  that  time,  without  being  psychologically  changed  for 
the  worse.  And  if  the  habit  goes  on  after  40,  the  change  is 
apt  to  be  faster  and  more  decided.  We  see  it  in  our  friends, 
and  we  know  what  the  end  of  it  will  be,  but  we  cannot  lay 
hold  on  anything  in  particular.  Their  fortunes  and  work 
suffer,  and  yet  you  dare  not  say  they  are  drunkards,  for  they 
are  not.  It  all  depends  on  the  original  inherent  strength 
of  the  "brain  how  long  the  downward  course  takes.  Usually 
some  intercurrent  disease  or  tissue  degeneration  cuts  off  the 
man  before  he  has  a  chance  of  getting  old.  I  have  seen  such 
a  man  simply  pass  into  senile  dementia  before  he  was  an  old 
man,  from  mild,  respectable,  alcoholic  excess,  without  any 
alcoholism  or  preUminary  outburst  at  all.     And  I  am  sure  I 


490  ALCOHOLIC  mSANITY. 

have  seen  strong  brains  in  our  profession,  at  tlie  bar,  and  in 
business,  break  down  from  chronic  alcoholic  excess  without 
their  owners  ever  having  been  many  times  drunk.  Such  men 
lose  their  memory.  Alcohohc  dementia  is  essentially  an 
amnesic  disease.  They  are  irritable,  and  have  no  originating 
power. 

Various  Drug  Insanities. — I  have  seen  many  cases  of 
insanity  resulting  from  opium-eating,  and  several  from  the 
hypodermic  use  of  morphia.  Those  were  very  like  the  insanity 
of  chronic  alcohoHsm,  but  not  so  suicidal,  with  greater  weak- 
ness of  the  heart's  action,  and  more  sleeplessness,  sickness,  and 
intolerance  of  food  for  the  first  fortnight.  It  is  precisely  the 
same  class  of  persons  v/ho  indulge  in  opium  who  indulge  to 
excess  in  alcohol,  and  the  treatment  is  the  same,  viz.,  stoppage 
of  the  drug,  which  may  have  to  be  regulated  and  gradual  in 
the  case  of  opium,  with  much  liquid  nourishment,  fresh  air, 
and  watching.  Sometimes  cardiac  stimulants  are  needed  in 
addition.  I  have  seen  two  cases  of  insanity  brought  on  by 
the  use  of  chloral.  They,  too,  were  of  the  same  generic  type 
as  the  alcohohc  cases,  and  demanded  the  same  treatment.  I 
have  seen  several  cases — all  medical  men,  I  regret  to  say — 
who  had  been  insane  through  hypodermic  use  of  cocaine.  The 
symptoms  were  more  acute.  There  were  more  hallucinations 
of  sight  and  more  sensory  disturbances  than  in  alcoholic  or 
opium  cases,  and  the  craving  for  the  drug  was  more  intense 
than  for  even  alcohol  or  opium.  Some  patients  combine 
these  drugs,  taking  both  opium  and  cocaine  or  alcohol  and 
opium.  ^ 

Pathological  Appearances  found  in  the  Brain  in   Chronic 

Alcoholic  Insanity.     If  alcohohc  excess  has  been  long  indulged 

in,  whether  there  have  been  marked  mental  symptoms  or  not, 

we  find  evidences  of  repeated  congestions  and  irritations  within 

the  cranium  in  the   shape  of  thickened  and  adherent  dura 

mater,  milky  arachnoid,  and  thickened  pia.     In  extreme  cases 

^   Vide  "Diseased  Cravings  and  Paralysed  Control,"  by  author,  Ed. 
Med.  Jour.,  Dec.  1889  to  May  1890. 


ALCOHOLIC   INSANITY.  491 

Ave  find  adherences  of  the  pia  to  the  convolutions,  and  granular 
linings  of  the  ventricles.  In  the  dementia  following  alcoholism 
there  is  always  marked  brain  atrophy. 

But  it  is  when  the  alcoholic  brain  is  examined  microscopi- 
cally that  the  most  evident  morbid  changes  are  seen.  Bevan 
Lewis  has  investigated  this  subject,  and  arrived  at  very  definite 
conclusions  as  to  the  pathology  of  chronic  alcoholism.^  "The 
vessels  dipping  into  the  cortex  from  the  pia  are  of  undue  size 
and  frequently  tortuous,  and  their  coats  are  in  advanced  stages 
of  atheromatous  and  fatty  change.  The  nuclei  of  the  adven- 
titial sheath  are  somewhat  numerous,  are  freely  proliferating, 
or  their  protoplasm  is  in  a  state  of  fatty  degeneration.  Far 
the  more  prominent  feature,  however,  is  the  abundance  of 
scavenger  cells  which  pervades  the  upper  or  outermost  region 
of  the  peripheral  zone  of  the  cortex  lying  immediately  beneath 
the  pia.  These  nucleated  protoplasmic  bodies  are  everywhere 
seen,  their  branching  processes  forming  a  dense  matting  which 
converts  the  outermost  fourth  of  this  cortical  layer  into  a 
closely  felted  substance  of  minute  meshes,  the  aspect  of  which 
differs  strikingly  from  that  normal  to  this  region.  Whenever 
a  blood-vessel  passes  downwards  through  the  cortical  layers 
these  scavenger  cells  are  more  numerous,  following  the  line  of 
vascular  channelling,  and  so  dipping  down  into  the  nerve 
elements  of  the  second  layer."  "  Beneath  the  pia,  betwixt  it 
and  the  surface  of  the  cortex  in  the  so-called  'epicerebral 
space '  we  often  find  a  vast  quantity  of  amyloid  bodies." 
"  Critically  examining  the  second,  and  third  layers  of  the 
cortex,  we  find  no  very  prominent  lesion."  "But  on  reaching 
the  large  motor  cells  of  the  fifth  layer  "  he  found  them  in  an 
advanced  stage  of  fatty  change,  and  together  with  the  layer 
of  spindle  cells  immediately  beneath  are  undergoing  extensive 
degeneration  and  absorption.  Fatty  embolisms  and  minute 
aneurismal  dilatations  are  also  commonly  found  in  the  small 
vessels  of  the  white  substance  of  the  brain.  His  general  con- 
clusion is  that  the  changes  observed  in  the  cortex  "are 
^  Text-Book  of  Mental  Diseases,  p.  528. 


492  ALCOHOLIC  INSANITY. 

undoubtedly  indicative  of  a  very  chronic  inflammatory  action 
proceeding  in  the  vessels  of  the  membranes,  and  slowly  in- 
volving the  upper  cortical  strata,"  The  two  great  morbid 
alterations  of  tissue  observed  by  Lewis,  it  will  be  observed,  are 
a  fatty  and  a  sclerotic  change.  But  in  addition  to  these  we 
find  much  granular  degeneration  in  the  ordinary  pyramidal 
cells,  as  seen  in  Plate  XIII.  fig.  5 ;  we  find  the  pia  mater 
thickened  as  in  general  paralysis  (Plate  XIV.  figs.  1  and  2), 
but  to  a  lesser  degree,  and  the  arterioles  tliickened  and  diseased 
as  shown  in  Plate  XV.  fig.  5,  where  the  thickenings  take 
the  form  of  localised  cellular  aggregations.  This  last  appear- 
ance is  more  common  in  alcohohc  insanity  than  in  general 
paralysis. 


LECTUEE   XIII. 

RHEUMATIC  AND  CHOEEIC  INSANITIES. 

Close  connection  between  chorea  and  rheumatism — Cerehro-spinal  rheu- 
matism— Rheumatic  insanity ;  pain  and  swelling  of  joints  cease  ; 
temperature  keeps  high  ;  fears;  delirium;  hallucinations;  tendency 
to  injury  ;  sleeplessness  ;  violent  chorea,  followed  by  temporary 
paralysis  ;  abatements  and  relapses  ;  symptoms  probably  result 
from  a  metastasis  of  rheumatic  morbid  action  from  joints  to  cord 
and  brain — Prognosis  :  Good — Treatment :  That  of  rheumatism — 
Delirium  of  chorea  an  inco-ordinated  mentalisation ;  long  continued 
chorea  tends  towards  dementia  in  children — Epidemic  choreic 
insanity. 

The  two  first  varieties  of  mental  disease  may  be  conveniently 
studied  together.  There  can  be  no  doubt  now  entertained 
as  to  the  close  connection  between  chorea  and  rheumatism ; 
as  we  shall  see,  this  connection  is  shown  very  vividly  in 
rheumatic  insanity,  which  is  also  an  acute  choreic  insanity. 
Cerebro-spinal  rheumatism  has  long  been  known,  but  in  some 
of  its  types  it  does  not  come  within  the  scope  of  a  book  on 
mental  disease.  In  one  variety  of  it,  however,  the  most 
prominent  symptoms  are  an  acute  dehrious  mania  and  choreic 
muscular  movements  of  a  violent  character.  The  ordinary 
course  of  an  attack  of  rheumatic  insanity  is  seen  in  the  folloic- 
ing  case  in  a  tyincal  form. 

J.  F.,  admitted  January  17,  1870,  set.  24,  married.  First 
attack  of  insanity.  Mother  died  of  consumption.  Father 
alive  and  well,  and  no  relative  insane  or  rheumatic.  In 
health  she  was  of  a  reserved  and  quiet  but  nervous  disposi- 
tion, steady  respectable  habits,  and  fond  of  her  children. 
The  predisposing  cause  of  her  illness  seemed  to  have  been  an 


494  EHEUMATIC   INSANITY. 

accumulation  of  debilitating  and  depressing  influences,  viz., 
ill-usage  by  ber  busband,  poverty,  cold,  hard  work,  with 
insufficient  food  during  the  tliree  years  since  sbe  was  married, 
and  having  nursed  her  second  child  for  fifteen  months  up 
to  the  period  of  her  attack.  These  things  caused  a  certain 
amount  of  depression  of  spirits.  The  exciting  cause  of  her 
malady  was  an  attack  of  rheumatism,  not  of  a  very  acute 
character,  which  had  lasted  for  two  months  before  she  be- 
came insane.  She  had  pains  in  the  back  of  her  neck,  pains 
and  much  sAvelling  of  fingers,  hands,  feet,  and  legs,  and  some 
f everishness ;  but  she  was  never  so  bad  as  to  be  quite  con- 
fined to  bed.  A  week  before  admission  she  suddenly  ceased 
to  complain  of  her  rheumatic  pains,  and  simultaneously  Avith 
this  rehef  she  showed  signs  of  mental  derangement,  and 
violent  chorea  of  head,  arms,  and  legs  commenced.  Her  first 
mental  symptoms  were  a  sort  of  absence  of  mind  and  in- 
attention to  what  was  passing  around  her,  taking  no  notice  of 
questions  put  to  her  or  of  her  children.  Before  being  sent  to 
the  Asylum,  in  addition  to  this  mental  inattention,  there  was 
great  excitement.  She  tore  her  clothes,  and  tried  to  jump 
out  of  a  second-storey  window  into  the  street.  She  was 
sleepless,  and  the  choreic  movements  had  increased  greatly  in 
intensity.  Her  limbs  were  never  still  a  moment,  and  she 
threw  her  whole  body  about. 

She  was  much  excited  on  admission,  her  memory  akaost 
gone,  and  with  difficulty  she  could  be  got  to  speak  at  all  in 
answer  to  questions,  but  talked  incoherently  in  monosyllables 
about  the  doctor  who  had  attended  her.  The  only  question 
she  could  be  got  to  answer  was  to  tell  her  name.  The 
existence  of  delusions  could  not  be  ascertained.  She  was  a 
dark-complexioned  woman  with  black  hair ;  rather  thin, 
muscles  flabby.  Eyes  dark  brown  and  sparkling  feverishly, 
pupils  contracted,  equal  in  size.  There  were  very  violent 
choreic  movements  of  the  muscles  of  her  face,  head,  arms, 
and  legs.  Anything  she  attempted  to  say  or  do  voluntarily 
was  accompanied  by  extravagant  grimaces,  twitchings,  and 


EHEUMATIC   INSANITY.  495 

contortions.  Reflex  action  was  diminished.  Could  not 
articulate  more  than  single  words  at  a  time,  and  those  im- 
perfectly. Could  not  stand  or  walk,  and  was  carried  with 
great  difficulty ;  no  tenderness  of  spine ;  lungs  normal,  re- 
spirations twenty  per  minute ;  heart  beating  quickly  but 
regularly,  no  cardiac  murmur.  Pulse  108,  strong.  Tongue 
clean  and  moist;  would  not  take  food.  Urine  clear,  acid, 
sp.  gr.  1015 ;  no  albumen  nor  deposits.  Had  not  menstruated 
since  beginning  of  last  pregnancy.  Temperature,  100*4°. 
Several  bruises  on  body,  especially  over  right  buttock.  She 
was  carried  to  bed  and  ordered  beef-tea  and  some  brandy. 
She  did  not  sleep,  and  on  the  following  day  the  choreic 
movements  of  the  legs  ceased,  these  becoming  quite  paralysed 
and  nearly  devoid  of  common  sensibility,  the  reflex  action  in 
them  being  absent.  Bladder  paralysed,  the  urine  having  to 
be  drawn  off  once,  after  wliich  she  could  pass  it.  Muscles  of 
eyelids  and  eyes  quite  under  control.  ISTot  so  the  tongue, 
which  she  could  scarcely  put  out  at  all,  and  then  with  a  jerk 
to  one  side.  Mental  excitement  abated,  and  speaks  better. 
M.  T.  99-4°,  E.  T.  99-6°,  M.  P.  80,  E.  P.  84.  Took  hquid 
food;  8  oz.  wine,  strong  beef -tea,  and  extra  diet.  She  im- 
proved slowly  until,  on  the  23rd  January — six  days  after 
admission — her  state  was  as  follows: — "Chorea  much  less 
severe,  complains  of  pain  in  knees,  evidently  of  a  nervous 
kind,  for  pressure  slowly  and  carefully  made  does  not  increase 
it.  Common  sensibihty  somewhat  exaggerated  in  legs,  and 
some  power  of  voluntary  movement  has  returned  to  them, 
but  she  has  little  reflex  movement.  Takes  food  well,  bowels 
regular,  no  sweating,  mentally  confused,  depressed,  no 
memory,  suspicious,  will  not  believe  a  word  said  to  her, 
wonders  where  she  is  and  how  she  came  here.  M.  T.  98*4°, 
E.  T.  99°,  M.  P.  108,  E.  P.  100." 

24:th  Jan. — To-day  twitching  of  fingers  only,  except  when 
she  attempts  any  voluntary  movements.  More  power  of 
voluntary  movement  in  left  leg  than  right,  which  is  almost 
paralysed.     Eight  knee  slightly  swollen.     Reflex  movements 


496  RHEUMATIC  INSANITY. 

slight,  and  more  active  in  left  than  right  leg.  Tongue 
twitches  when  put  out,  and  goes  towards  right  side.  Tem- 
perature the  same.  She  has  hallucinations  of  sight  and 
touch,  saying  that  she  sees  an  old  woman  coming  behind  her 
and  eating  her  food,  so  that  she  cannot  get  any  of  it,  and 
that  one  foot  has  been  cut  off.  Is  depressed,  weeps  and 
groans. 

29^7i  Jan. — Has  had  a  relapse ;  chorea  worse  in  left  arm ; 
complains  of  pains  in  arms  and  legs.  Complains  of  a  burning 
feeling  all  over  her.  A  large  slough  forming  in  right  buttock 
where  it  had  been  bruised.  She  complains  much  of  the  pain 
of  this.  She  still  cannot  tell  correctly  the  place  touched  on 
her  legs,  but  when  pinched  she  screams.  Eequires  to  be  fed 
with  a  spoon,  shows  a  mental  aversion  to  food,  though  she  is 
evidently  hungry.  M.  T.  100°,  E.  T.  97°,  M.  P.  116,  E.  P. 
116.  She  has  no  affection  of  sight,  and  no  sparks  nor  motes 
before  her  eyes. 

bth  Feb. — She  now  has  so  far  recovered  the  power  of  her 
legs  that  she  can  stand.  Chorea  almost  gone  when  she  makes 
no  voluntary  movements.  Mentally  a  mixture  of  stupor  and 
depression,  as  before,  and  the  hallucinations  of  sight  and 
touch  remain.  M.  T.  99-8°,  E.  T.  101°,  M.  P.  120,  E.  P. 
120. 

She  gradually  but  not  quite  steadily  improved,  and  her 
temperature  fell  until,  on  the  19th  February,  she  was  re- 
ported as  having  only  very  slight  chorea  in  hands,  but  as 
still  complaining  of  the  pains  in  legs.  Mentally  she  was 
still  confused,  but  her  memory  was  returning.  M.  T.  98 "2°, 
E.  T.  98°,  M.  P.  94,  E.  P.  100. 

2nd  April. — "  Believes  now  what  she  is  told,  and  is  almost 
rational ;  but  her  right  hand  is  swollen,  though  quite  painless. 
Chorea  rather  worse,  and  she  cannot  sleep  so  well  as  usual." 
The  sleeplessness  increased,  and  the  choreic  movements  began 
to  trouble  her  exceedingly  at  night,  and  on  the  4th  her  M.  T. 
was  99'2°  and  her  pulse  104  and  weak.  As  an  experiment 
I  gave  her  20  grains  of  chloral  in  the  morning,  which  made 


KHEUMATIC   INSANITY.  497 

lier  slightly  drowsy,  and  quite  stopped  the  choreic  move- 
ments till  the  evening,  when  they  came  on  again,  and  she 
could  tiot  sleep.  I  then  gave  her  40  grains  of  chloral.  She 
slept  soundly ;  the  chorea  ceased ;  her  temperature  next 
morning  was  97*3°,  and  her  pulse  84  and  stronger.  Her 
mind  had  not  been  affected  during  this  little  aggravation  of 
the  chorea.  The  swelHng  of  the  hand  remained  for  a  day  or 
two  longer,  and  then  gradually  disappeared.  Still  the  reflex 
action  in  foot  was  diminished,  and  she  complained  of  intense 
heat  of  hands.     Wound  on  buttock  healed  up  slowly. 

22nd  April. — No  chorea  now  except  when  she  smiles ;  she 
then  grins  and  looks  nervous  in  her  movements.  Sleeps  and 
eats  well.  Industrious  and  rational.  Has  only  gained  two 
pounds  in  weight  in  a  month.  M.  T.  98-4°,  E.  T.  98°,  M.  P. 
96,  E.  P.  84. 

Her  recollection  of  the  coming  on  of  the  disease  is  im- 
perfect, and  she  has  no  remembrance  of  the  choreic  move- 
ments beginning.  Her  mind  must  have  been  affected 
simultaneously  with  their  appearance  or  before  them.  She 
does  not  even  recollect  the  rheumatic  pains  disappearing. 
She  says  that  she  had  no  conscious  feeling  of  weakness  or 
exhaustion  from  the  nursing  before  the  rheumatism  began. 
Her  recollection  of  events  which  occurred  during  the  first 
month  of  her  illness  is  very  imperfect. 

29th  April. — During  the  past  week  has  gained  five  pounds 
in  weight,  and  is  now  cheerful,  rational,  and  says  she  feels 
perfectly  well.  Muscles  under  her  control.  From  that  time 
her  perfect  recovery  was  steady  and  rapid. 

Is  any  light  thrown  on  the  relations  between  rheumatism, 
chorea,  and  insanity,  or  on  the  connection  between  motor  and 
psychical  abnormahty,  by  the  case  I  have  related  1  "Was  the 
rheumatism  the  true  cause  of  the  mental  symptoms,  of  the 
chorea,  or  of  both?  Were  these  abnormal  afi"ections  of 
motion  and  the  perverted  psychical  manifestations  the  result 
of  an  identical  and  simultaneous  lesion  afi'ecting  both  the 
motor  and  mental  centres?     Or  was  the  one  dependent  on 

2  I 


498  EHEUMATIC  INSANITY. 

the  other,  secondary  to  it,  or  sympathetic  with  it  ?  Is  it  not 
evident  that  in  this  case  we  have  a  distinct  form  of  insanity, 
a  form  about  wliich  much  may  be  ascertained  by  a  careful 
study  of  its  relation  to,  and  its  correlation  with,  the  motor 
symptoms  ?  It  will  be  observed  that  nearly  all  the  functions 
of  the  nervous  system  were  here  affected, — the  nutrition,  heat 
production,  motion,  sensation,  reflex  action,  the  special  senses, 
the  memory,  and  the  intellectual  processes  all  at  the  same 
time,  and  they  recovered  their  normal  action  about  the  same 
time. 

I  think  it  cannot  be  doubted  by  any  one  that  the  rheuma- 
tism was  the  true  cause  both  of  the  chorea  and  the  insanity 
in  this  case.  All  the  symptoms, — the  coming  on  of  the 
disease,  the  choreic  movements,  the  paralysis  of  motor 
power,  the  deadening  of  reflex  action  of  the  legs,  the  hallu- 
cinations of  sight,  touch,  and  taste,  the  want  of  memory, 
the  acute  dehrium  with  unconsciousness  of  anything  going 
on  around,  succeeded  by  confusion  of  ideas,  suspiciousness, 
and  sluggishness  of  mind,  the  high  temperature  increased  at 
night,  the  tendency  to  improvement  in  all  the  symptoms 
coincidently  with  the  lowering  of  the  temperature,  and  the 
slowness  of  the  convalescence — all  these  things  show  that 
some  lesion  of  the  central  nervous  system  existed.  And 
when  this  is  taken  along  with  the  fact  that  such  a  train  of 
symptoms  suddenly  appeared  in  the  course  of  an  attack  of 
rheumatism,  that  the  symptoms  of  the  articular  rheumatism 
at  once  disappeared,  while  the  fever  did  not  do  so,  and  that 
in  this  woman,  when  she  was  nearly  well,  rheumatic  swelling 
of  the  knuckles  of  one  hand  appeared  along  with  aggravated 
choreic  movements,  sleeplessness,  and  an  increase  of  tempera- 
ture, we  have  very  strong  data,  not  only  to  conclude  that 
rheumatism  was  the  cause  of  the  nervous  and  mental 
symptoms,  but  that  here  we  have  a  true  and  typical  example 
of  a  rheumatic  insanity,  which  must  be  classed  by  itself  as" 
a  special  form  of  mental  disease,  and  a  true  pathological 
entity. 


RHEUMATIC   INSANITY.  499 

A  Theory  of  Causation. — As  to  how  tlie  nervous  system 
was  affected,  may  we  not  form  a  probable  hypotliesis  1  We 
know  how  rheumatic  disease,  whatever  it  is,  affects  the  other 
tissues.  We  know  also  sometliing  of  the  kind  of  lesions  of 
the  spinal  cord  which  are  needed  to  produce  paraplegia 
and  the  total  absence  of  reflex  action,  even  if  we  do  not 
know  fully  the  pathology  of  chorea  or  of  insanity.  In 
regard  to  the  motor  affection  of  the  legs,  we  saw  that  at  first 
there  was  violent  choreic  movement,  which  was  succeeded 
by  complete  paralysis  of  motion,  no  reflex  movement,  and 
greatly  diminished  common  sensibility.  As  the  power  of 
motion  returned,  Avhich  was  in  the  course  of  a  few  days, 
there  was  hyperaesthesia  and  a  sensation  of  heat.  Does  not 
this  sequence  of  phenomena  indicate  a  serious  but  transitory 
interference  with  the  functions  of  the  nerve-cells  and  fibres 
in  the  spinal  cord,  such  as  might  be  produced  by  slight 
rheumatic  inflammation  and  infiltration  of  the  connective 
tissue  of  the  cord,  causing  pressure  on  the  nerve  elements  1 
If  the  nerve-cells  or  fibres  had  been  themselves  attacked  with 
any  inflammatory  affection,  they  would  not  have  so  soon 
regained  their  function.  We  know  the  rheumatic  poison 
has  a  special  tendency  to  affect  the  connective  tissue.  The 
rheumatic  pains  in  the  limbs  are  caused,  we  cannot  doubt, 
either  by  pressure  on  the  small  nerves  or  by  a  rheumatic 
neuritis.  And  if  the  cord  was  affected  in  this  way,  is  it  not 
probable  that  the  same  thing  took  place  in  the  brain  centres 
that  minister  to  special  sensation,  and  also  in  the  mental 
portions  of  the  organ  ?  The  raised  temperature  and  the 
strongly  acid  urine  remained  the  same,  whether  the  rheumatic 
inflammation  was  in  the  joints  or  in  the  central  nervous 
system.  But  when  the  inflammation  had  passed  away,  the 
effects  were  far  longer  visible  in  the  delicate  tissue  of  the 
nervous  centres  than  in  the  joints. 

In  this  case  the  insanity  might  be  described  as  a  metastatic 
one,  if  such  a  term  were  strictly  applicable  to  the  effects  of  a 
poison  or  germ  in  the  blood  whose  effects  are  first  seen  in  one 


500  KHEUMATIC   INSANITY. 

set  of  tissues  and  tlien  in  another  set.  The  shght  relapse, 
when  the  hand  and  the  spinal  cord  Avere  both  affected  at 
the  same  time,  showed,  however,  that  the  effects  of  the 
toxic  agent  need  not  be  absolutely  limited  to  one  sort  of 
tissue.  There  was  no  ascertainable  trace  of  a  tendency  to 
heart  disease  in  the  case. 

It  would  seem  that  in  such  a  lesion  of  the  spinal  cord  as 
occurred  in  this  case,  the  common  sensibility  was  the  last  to 
be  abolished  and  the  first  to  come  again ;  then  the  voluntary 
motor  power  returned,  then  the  reflex  action,  and,  last  of  all, 
the  power  of  the  nerves  which  preside  over  nutrition.  That 
the  sensory  and  motor  functions  should  have  been  less  inter- 
fered with  than  the  reflex  action  is  what  might  have  been 
expected,  when  we  consider  that  the  greater  number  of  the 
nerve-fibres  ministering  to  the  two  former  merely  pass  through 
the  cord,  while  the  nerve  cells  forming  the  ganglia  which  sub- 
serve the  latter  function,  lie  in  the  cord  itself.  The  cord  was 
evidently  more  affected  than  the  brain. 

It  was  not  until  all  the  other  functions  were  restored  that 
the  trophic  power  returned,  and  the  patient  began  to  gain 
in  weight  rapidly.  The  slough  that  formed  over  the  buttock 
from  the  bruise,  and  the  slow  healing  of  the  wound,  showed 
how  much  it  was  affected  at  first.  In  regard  to  the  special 
senses,  sight  was  first  affected  and  then  taste,  and  they  were 
restored  in  inverse  order.  Of  the  purely  psychical  functions, 
memory  and  the  power  of  voluntary  attention  were  first 
affected,  then  the  coherence  and  balance  of  the  mental  powers 
was  upset,  and,  lastly,  the  whole  of  the  mental  operations 
were  merged  in  the  acute  deHrium  and  utter  incoherence 
present.  Curiously,  in  all  the  patients  labouring  under  this 
disease  that  I  have  seen,  there  were  suspicions  of  those  about 
them,  and  entire  scepticism  as  to  what  they  were  told  about 
the  most  simple  matters  during  convalescence.  The  healthy 
elasticity  of  mind  and  enjoyment  of  hfe,  which  constitute  the 
most  certain  proof  that  the  brain  is  performing  all  its  fiinctions 
normally,  were  the  last  to  return,  and  corresponded  to  the 


EHEUMATIC  INS  A.NITY.  501 

restoration  of  function  of  the  centres  of  nutrition  and  the 
commencement  of  a  rapid  increase  in  weight  of  the  whole 
body. 

That  was  the  first  case  of  rheumatic  insanity  I  ever  met 
with,  and  it  has  been  the  best ;  but  I  have  met  with  many 
cases  of  the  same  type  since.  One  had  an  attack  of  chorea 
in  youth,  though  without  rheumatic  symptoms,  I  had  one 
woman  in  whom  the  disease  was  very  severe,  and  ended 
in  complete  paraplegia  and  death  in  a  few  months.  I  found 
the  cord  to  have  undergone  a  destructive  inflammation  and 
softening  in  all  its  columns  pretty  nearly  throughout  its 
entire  length.  I  had  lately  a  case  in  which  the  mental 
symptoms  did  not  go  on  -  to  delirium,  but  stopped  short  at 
morbid  suspicions  and  sensory  hallucinations ;  she  recovered 
in  two  months.  In  relationship  to  rheumatic  insanity  one 
should  keep  in  mind  the  spinal  and  osseous  lesions  in  chronic 
rheumatism  pointed  out  by  Charcot. 

The  treatment  of  such  cases  is  just  the  modern  treatment 
of  acute  rheumatism,  with  the  nursing  and  care  suitable  for 
a  bad  delirious  kind  of  mania  in  addition.  The  prognosis  is 
favourable  in  most  cases.  The  disease  is  rare.  All  the  cases 
of  rheumatic  insanity  which  I  have  met  with,  have  been  in 
the  developmental  period  of  life,  before  25. 

Choreic  Insanity  loithout  Acute  Rheumatism. — We  may  have 
a  choreic  insanity  both  in  early  youth — the  common  time  for 
chorea — and  in  more  advanced  life  without  any  acute  rheumatic 
symptoms.  The  delirium  is  then,  as  Maudsley  points  out,  of 
an  inco-ordinated,  jerky  kind,  like  the  muscular  movements. 
Such  a  delirium  is  apt  to  come  in  bursts,  and  to  pass  away 
quickly.  In  the  cases  of  chronic  chorea  the  mental  affection 
is  often  depression  at  first,  then  mania  with  impulsive  acts 
of  violence  or  suicide,  and  then  dementia  in  the  end.  Some 
of  these  cases  are  very  sad  from  the  sufferings — mental  and 
physical — the  patients  undergo  through  their  involuntary 
jactitations.  I  had  a  man,  J.  G.,  who  frequently  had  to  be 
placed  in  a  padded  room  to  protect  him  from  the  bruisings  he 


502  EHEUMATIC  INSANITY. 

would,  otherwise  have  inflicted  on  liimself .  He  at  last  literally 
wore  himself  out.  One  is  justified  in  keeping  such  cases  under 
the  influence  of  cliloral,  sulphonal,  and  the  bromides  to  de- 
crease their  sufi'erings.  Sleep  in  any  form,  and  induced  by  any 
means,  is  to  them  a  blessing,  for  it  is  the  only  time  they  are  at 
rest  and  peace.      Hyoscine  may  be  used  in  very  acute  cases. 

In  many  forms  of  insanity  there  are  choreiform  and  rhyth- 
mical movements  that  may  be  called  ideo-motor.  I  had  a 
case  of  general  paralysis,  J.  H.,  in  which  the  patient's  left 
hand  was  always  engaged  in  rubbing  his  trousers  with  his 
thumb  and  forefinger.  I  have  now  a  case  of  excited  melan- 
choHa,  J.  L.,  a  lady,  who  makes  the  most  extraordinary 
choreiform  faces  and  grimaces  in  a  sort  of  automatic  unthink- 
ing way.  She  says  it  is  a  relief  to  her  to  do  so.  This  sort 
of  movement  is  common  among  the  insane,  and  I  look  on 
it  as  being  in  many  of  them  closely  allied  to  chorea. 

The  treatment  of  all  kinds  of  choreic  insanity  is,  first, 
tonic  and  nutritive,  and  then  anti-rheumatic.  I  have  had 
one  or  two  cases  where  arsenic  seemed  to  work  wonders.  I 
have  had  other  cases  where  the  bromides  given  as  for  epilepsy 
did  good.  Iron,  too,  and  zinc,  and  the  valerianates,  are  all 
good  in  some  cases.  Cold  to  the  spine  in  certain  cases  tempo- 
rarily stops  the  movements. 

In  the  Middle  Ages  there  used  to  be  wonderful  epidemics 
of  St  Vitus'  dance,  with  morbid  mental  symptoms,  aff"ecting 
at  the  same  time  thousands  of  persons  by  a  kuid  of  morbid 
sympathy  and  imitation.  Mankind  seems  less  subject  to 
these  strange  imitative,  uncontrollable,  mental-motor  epidemics 
now  than  it  was  several  hundreds  of  years  ago,  but  in  1887 
there  appeared  in  the  newspapers  an  account  of  an  "  epidemic 
of  hysteria  "  in  Italy,  which  was  attended  by  maniacal  and 
motor  symptoms,  to  put  an  end  to  which  the  police  had  to 
be  called  in  and  the  patients  sent  to  gaol ! 


GOUTY  INSANITY.  503 


,    ,  ,     GOUTY  OR  PODAGROUS  INSANITY. 

A  rare  disease  ;  morbid  mental  condition  very  common  in  gout ;  Syden- 
ham's description — "Gouty  Mania" — Prognosis:  Good;  duration 
short — Termination :  Recovery  or  congestion  of  brain. 

This  is  a  rare  disease  in  forms  sufl&cieiitly  marked  to  come 
under  specialist  treatment  or  to  be  regarded  as  technically 
mental  disease ;  but  mental  phenomena  due  to  gout  are  com- 
mon enough,  and  have  been  described  by  all  authors  on  the 
subject.  Irritability,  incapacity  for  mental  exertion,  and  de- 
pression are  the  most  common  of  these.  Sydenham  gives  a 
good  description  of  them  in  his  classic  work  on  gout.  "  The 
body  is  not  the  only  sufferer,  and  the  dependent  condition  of 
the  patient  is  not  his  worst  misfortune.  The  mind  suffers 
with  the  body,  and  which  suffers  most  it  is  hard  to  say.  So 
much  do  the  mind  and  reason  lose  energy  as  energy  is  lost  by 
the  body — so  susceptible  and  vacillating  is  the  temper — such 
a  trouble  is  the  patient  to  others  as  well  as  to  himself — that  a 
fit  of  gout  is  a  fit  of  bad  temper."  The  above,  no  doubt,  is 
the  most  common  mental  effect  of  gout,  but  it  does  not  amount 
to  mental  disease.  Deep  melancholia  is  a  common  accompani- 
ment of  the  gouty  diathesis,  especially  about  the  climacteric 
and  early  part  of  the  senile  periods.  I  have  had  several 
cases  of  intense  suicidal  melancholia  at  this  period  of  life 
in  patients  with  a  strong  gouty  heredity  and  gouty  deposits, 
but  who  had  not  been  subject  to  the  regular  acute  attacks. 
I  have  one  such  case  now,  J.  M.,  aged  53  on  admission,  with 
a  strongly  gouty  heredity  and  acquired  syphilis,  who  was 
always  more  or  less  dyspeptic,  and  suffered  from  constipation. 
He  always  had  marked  psoriasis,  and,  latterly,  gouty  deposits 
on  lobes  of  ears.  Before  he  became  affected  in  mind  he  fell 
off  in  flesh,  his  skin  eruption  disappeared,  he  became  very 
costive,  and  a  very  dilated  sigmoid  flexure  was  found  to  exist. 
Sleeplessness  and  strong  suicidal  impulses,  with  delusions  as 
to  his  trouble,  were  the  chief  characteristics  of  his  depression. 


504  PHTHISICAL  INSANITY. 

his  reasoning  power  otherwise  being  good.  Every  kind  of 
medical  treatment  —  anti- gouty,  anti- syphilitic,  soporific, 
sedative,  and  tonic — was  tried  in  vain.  Nothing  really 
seemed  to  do  him  good  except  feeding,  with  an  excess  of 
milk  and  eggs,  sugar  and  fresh  vegetables — which  had  to  be 
given  at  first  by  the  nose-tube — and  living  out  in  the  fresh 
air.  He  got  fat,  and  his  sleep  returned  in  about  nine  months, 
the  acute  misery  disappearing.  For  several  years  past  he 
has  exhibited  a  recurrence  of  the  melancholia  every  second 
day,  with  alternate  days  of  freedom.  He  gained  two  stone 
in  weight  under  treatment — a  great  nutritive  triumph  in 
such  a  subject.  There  were  signs  of  sKght  degenerative 
tissue  changes  in  him  in  the  nerves  or  nervous  centres,  or 
both,  evidenced  by  a  partial  paralysis  of  the  ring  and  httle 
fingers  of  the  left  hand,  with  wasting  of  the  muscles.  He 
lived  twelve  years  in  the  Asylum  and  died  at  65,  of  kidney 
and  heart  disease  in  addition  to  some  paralytic  symptoms. 
No  post-mcni.em  examination  was  permitted.  Garrod  describes 
"gouty  mania"  as  a  very  acute  delirious  aifection,  occurring 
in  some  patients  immediately  after  the  cessation  of  the  acute 
joint  affections.  Along  with  the  mania  there  is  heat  of  head 
and  high  fever.  In  one  such  case  which  he  describes,  all  the 
mental  symptoms  passed  off  when  one  toe  became  affected 
in  the  ordinary  way.  This  kind  of  acute  gouty  insanity 
either  terminates  quickly  in  recovery,  or  runs  on  to  congestion 
and  inflammation  of  the  membranes  of  the  brain. 


PHTHISICAL  IIs^SAMTT. 

Brain  Anfemia  and  its  mental  effects — Phthisis  much  more  common 
among  the  insane  than  the  sane — A  special  connection  between 
the  phthisical  and  the  insane  diathesis  hereditarily  and  other- 
wise ;  frequent  occurrence  of  the  two  diseases  in  different  members 
of   same  family — Phthisical    insanity  ;    suspicion  ;    slight   mental 


PHTHISICAL  INSANITY.  505 

weakness  ;  unsocialness  ;  slight  attacks  of  excitement ;  monomania 
of  suspicion  in  some  cases ;  variableness  of  mind — the  phthisical 
mind  ;  death-rate  from  phthisis  in  asylums  has  little  connection 
with  phthisical  insanity — ansemic  brain  ;  nutrition  and  digestion 
weak  ;  mental  danger  of  pretubercular  stage  of  phthisis  ;  insanity 
begins  before  the  phthisis  commonly — Phthisical  insanity  forms 
3  per  cent,  of  all  cases  of  insanity — Treatment :  That  of  phthisis 
and  its  diathesis  —  Prognosis  :  Unfavourable,  but  30  per  cent, 
recover. 

Brain  Ancemia. — An  anaemic  brain,  from  whatever  cause, 
is  always  prone  to  disturbance  of  function.  Lack  of  blood 
means  imperfect  nourishment  and  unstable  energising. 
Where  we  have  so  vascular  a  tissue  as  the  grey  substance  of 
the  brain  convolutions,  there  the  blood  is  needed  in  largest 
amount  and  best  quahty  if  we  are  to  have  healthy  and 
vigorous  mentalisation.  Every  one  who  has  experienced  any 
disease  that  has  thinned  and  lessened  the  blood  has  felt  the 
difference  in  his  mental  power  then  as  compared  with  health. 
The  physiological  effects  of  depriving  the  brain  of  part  of  its 
blood,  or  even  of  lowering  the  blood  pressure,  are  different  in 
different  cases  to  some  extent.  In  this,  as  in  other  ways  in 
human  beings,  the  strong  and  the  weak  hereditary  qualities 
of  a  brain  come  out.  One  man  has  merely  singing  in  his  ears, 
a  tendency  to  faintness,  or  a  profound  mental  lassitude  and 
paralysis  of  voHtion,  amounting  almost  to  torpor ;  those  being 
probably  the  purely  physiological  mental  results  of  a  bloodless 
brain.  Another  man  becomes  intensely  supersensitive  and 
over-excitable,  suffering  torture  from  sounds  and  circumstances 
that  in  health  would  have  been  calmly  borne ;  another  cannot 
sleep ;  another  has  hallucinations  of  the  senses ;  another  takes 
convulsions  long  before  that  amount  of  blood  is  lost  that 
necessarily  causes  convulsions ;  and  another  becomes  dehrious, 
or  is  attacked  with  insanity.  The  same,  or  rather  far  greater 
differences  of  brain  symptoms,  result  from  diseases  and  morbid 
conditions  that  cause  or  are  specially  accompanied  by  ansemia. 
The  cachexise,  the  blood-poisonings,  and  the  diseases  of 
nutrition  in  which  blood  is  not  made  in  sufficient  quantity. 


506  PHTHISICAL  INSANITY. 

may  all  be  attended  with  danger  to  some  brain  functions, 
though  certain  brains  seem  to  have  the  innate  trophic  energy 
to  nourish  their  tissues  and  perform  their  functions  on  less 
blood  than  others.  In  those  predisposed  by  heredity  to  dis- 
turbance or  enfeeblement  of  the  mental  functions,  it  is  the 
mind  that  chiefly  suffers  in  conditions  of  bloodlessness.  We 
are  entitled  to  assume  that  the  convolutions  of  such  brains 
have  less  than  the  normal  trophic  and  functional  energy. 
After  death,  in  such  cases,  the  whole  brain,  but  more  especi- 
ally the  convolutions  of  the  anterior  lobes  and  the  vertex, 
are  often  found  disproportionately  anaemic  as  compared  with 
the  other  organs  of  the  body ;  and  the  brain  is  not  only  found 
anaemic,  but  manifestly  wanting  in  normal  consistence,  in 
sorae  cases  atrophied  to  some  extent,  and  in  others  presenting 
an  appearance  closely  resembling  the  first  stage  of  necrosis 
from  brain  embohsm.  In  all  such  cases  its  specific  gravity 
is  lessened.  Chemical  analysis  of  the  brain  has  not  as  yet 
reached  that  point  of  certainty  that  it  can  tell  us  what  con- 
stituents are  specially  wanting  in  such  diseased  conditions. 
In  patients  that  have  been  insane,  and  had  pulmonary  con- 
sumption, I  have  seen  the  most  marked  brain  anaemia,  low 
brain  specific  gravity,  irregular  vascularity,  and  the  softest 
brain  texture  that  I  have  met  with,  not  to  have  been  cases 
of  "  white  softening "  from  embohsm  or  other  local  cause  of 
brain  starvation. 

Scrofula  and  Phthisis  in  Idiocy  and  Insanity. — The  frequent 
association  of  the  depraved  nutritive  condition  known  as 
"  scrofulous,"  with  idiocy  and  congenital  imbecility,  is  well 
known  and  universally  recognised  by  those  who  have  had 
experience  of  such  cases,  two-tlairds  of  whom  ultimately  die 
of  tubercular  disease.  The  common  occurrence  of  pulmonary 
phthisis  as  a  cause  of  death  among  the  insane  had  been  long 
noted  by  those  having  charge  of  the  older  lunatic  asylums. 
A  special  connection  between  the  scrofulous  and  phthisical 
constitutions  and  the  insane  predisposition  had  been  pointed 
out   by  Van  der   Kolk   and   others.     The    short   attacks   of 


PHTHISICAL  INSANITY.  507 

delirium  to  which  some  phthisical  patients  are  subject  had 
been  described  by  Morel.  And  that  pleasant  unreason,  the 
spes  phthisica,  had  been  known  from  classic  times.  But  any 
special  manifestation  of  mental  disorder  directly  connected  with 
pulmonary  consumption  had  not  been  described  till  in  1863  I 
did  so,  as  the  result  of  a  very  careful  clinical  and  statistical 
inquiry  into  the  matter.  I  was  led  to  the  conclusion  that  such 
a  connection  existed  on  clinical  grounds  as  well  as  statistical  ;^ 
hence  I  caUed  the  form  of  mental  disease  Phthisical  Insanity, 
which  is  now  generally  recognised.  ISo  doubt  consumption  was 
startlingly  more  frequent  as  a  cause  of  death  among  the  in- 
mates of  the  older  asylums  than  in  the  modern  institutions; 
but  still  it  is  in  all  asylums  for  the  insane  between  three  and 
four  times  more  common  than  in  the  general  population  cd 
the  same  ages.  In  the  Eoyal  Edinburgh  Asylum  it  has  fallen 
almost  to  one-half  in  the  past  ten  years  under  improved 
hygienic  conditions  compared  with  the  period  of  1842-1861. 
But  that  has  nothing  to  do  with  the  2 "7  per  cent,  of  my 
patients  that  I  classify  on  admission  as  phthisical  insanity  on 
account  of  their  mental  and  bodily  peculiarities,  which  I  shall 
presently  describe. 

'So  doubt  brain  anaemias  of  all  kinds,  and  from  whatever 
causes,  are  apt  to  produce  mental  conditions  like  phthisical 
insanity,  and  in  some  individual  cases,  I  admit,  quite  indis- 
tinguishable from  it.  It  is  said  that  insanity  is  infrequent  in 
hospitals  for  consumption.  It  may  be  that  such  mental  dis- 
turbance as  would  be  probably  reckoned  technical  insanity  is 
not  common  in  such  institutions,  but,  so  far  as  I  am  aware, 
we  have  no  statistics  on  that  question.  We  have  only  one 
person  in  every  2100  of  the  general  population  becoming 
insane  every  year;  and  if  one  in  every  1000  of  the  persons 
already  phthisical  became  insane,  that  would  not  bulk  largely 
in  the  mind  of  a  physician  to  an  hospital  for  consumption 
whose  attention  was  not  directed    to  the  matter,  though   it 

^  "The  Connection  between  Tuberculosis  and  Insanity,"  Jownta^  of 
Mental  Science,  April  1863. 


508  PHTHISICAL  INSANITY. 

would  be  an  increase  of  insanity  of  100  per  cent,  over  the 
general  population.  But  the  great  reason  why  insanity  is 
not  common  in  hospitals  for  consumption  is  simply  that  it 
usually  appears  before  the  lung  symptoms  of  the  phthisis 
have  appeared  in  great  intensity,  and  is  therefore  sent  to 
lunatic  asylums  instead. 

I  have  the  satisfaction  of  knowing  that  many  acute  clinical 
observers  have  supported  my  conclusion  that  there  is  a  phthisi- 
cal insanity,  Dr  IMaudsley  going  the  length  of  saying  that  he 
has  seen  many  cases  exhibiting  a  phthisical  mindedness  not 
amounting  to  technical  insanity,  less  in  degree  but  the  same 
in  kind. 

l!fo  doubt  my  clinical  experience,  since  1863,  has  modified 
to  some  extent  some  of  my  conclusions  of  that  date.  For 
instance,  I  do  not  now  look  on  phthisical  insanity  as  being 
so  incurable  a  condition  as  I  did  then ;  but  I  had  not  then 
had  the  experience  of  the  working  of  the  most  modern 
hygienic  ideas  in  asylums,  or  of  the  most  recent  modes  of 
treating  the  insane  therapeutically  and  morally.  But,  on  the 
other  hand,  my  experience  has  strengthened  my  conviction 
that  a  phthisical  insanity  exists,  and  in  the  typical  cases  that 
it  is  well  marked  in  its  characters,  and  that  it  is  different  in 
many  essential  points  from  any  of  the  other  forms  of  anaemic 
or  diathetic  insanities.  It  does  not  arise  in  asylums  through 
any  defects  in  their  hygienic  conditions  or  otherwise.  The 
patients  labour  under  it  when  they  come  into  asylums.  Its 
existence  and  amount  have  no  fixed  relationship  to  the  death- 
rate  from  phtliisis  in  the  institution  at  all,  for  I  find  that 
while  in  the  nineteen  years  1842-61  the  death-rate  from  this 
disease  in  the  Royal  Edinburgh  Asylum  was  29  per  cent.,  I 
estimated  in  1863,  from  the  symptoms  of  patients  put  down 
in  the  Case-Books,  that  for  the  ten  previous  years  about  3 
per  cent,  of  the  admissions  were  cases  of  phthisical  insanity ; 
and  in  the  nine  years  1874-82,  when  the  mortahty  from 
phthisis  has  only  been  135  per  cent.,  I  have,  from  my  own 
personal  knowledge  of  each  case,  diagnosed  and  recorded  at 


PHTHISICAL  INSANITY.  509 

the  time  2"7  per  cent,  of  those  admitted  as  suffering  from 
phthisical  insanity.  Those  two  things,  therefore,  so  liable 
to  be  confounded  with  each  other,  the  general  death-rate 
from  phthisis  and  the  number  of  cases  of  phtliisical  insanity 
admitted  into  an  institution,  must  be  kept  entirely  apart. 

Symptoms. — The  general  characters  of  phtliisical  insanity 
are  such  as  might  be  expected  to  be  found  in  persons  of  weak 
vitality.  There  is  no  acuteness  or  vigour  about  the  symptoms 
of  the  disease.  Looked  at  solely  from  the  point  of  view  of 
the  mental  symptoms  present,  some  of  the  cases  would  be 
called  mania  of  the  mildly  delusional,  slightly  demented  type ; 
more  of  them  would  be  called  melancholia,  also  of  the  mildly 
delusional  type;  and  many  of  them  would  be  called  mono- 
mania of  suspicion  or  of  unseen  agency.  It  is  a  very  striking 
fact  in  regard  to  the  last,  that  nearly  all  pure  cases  of  mono- 
mania of  suspicion  sooner  or  later  die  of  phthisis.  The 
symptom  of  a  morbid  mental  suspicion  runs  through  all  the 
cases  of  phthisical  insanity.  Sometimes,  but  not  commonly, 
they  have  an  acute  stage  at  first,  but  tliis  is  always  short. 
Most  frequently  the  disease  begins  by  a  gradual  alteration  of 
disposition,  conduct,  and  feeling  in  the  direction  of  morbid 
suspicion  of  those  about  the  patient,  a  morbid  fickleness  of 
purpose,  an  unsociability,  an  irritabihty,  and  an  entire  want 
of  buoyancy  and  proper  enjoyment  of  life.  Along  with  this 
there  is  a  loss  of  weight,  indigestion,  intolerance  of  fat,  want 
of  enjoyment  of  food,  perversion  of  taste  in  regard  to  food, 
and  a  bad  colour  of  the  skin.  There  may  or  there  may  not  be 
any  definite  chest  symptoms  present.  Then  comes  the  acutest 
part  of  the  attack,  if  there  is  such  a  stage  in  the  case. 
The  patient  gets  sleepless  and  mildly  melancholic  or  manical, 
the  bodily  state  running  down  all  the  time.  The  organic 
enfeeblement  that  characterises  the  disease  is  often  shown  by 
refusal  of  food.  The  patient  thinks  he  is  being  poisoned,  this 
no  doubt  being  the  convolutional  misinterpretation  of  the  pain 
and  uneasiness  of  indigestion.  In  a  way,  he  is  poisoned,  for 
his  food  is  badly  digested  and  assimilated,  and  the  subjective 


510  PHTHISICAL   INSANITY. 

sensations  accompanying  tins  are  not  so  unlike  some  kinds  of 
poisoning.  After  a  little  the  patient  becomes  irritable,  sullen, 
unsociable,  and  suspicious,  his  state  varying  from  time  to  time. 
The  intellectual  processes  are  not  so  much  enfeebled  as  that 
there  is  a  disinclination  to  exercise  them.  There  are  occasional 
unaccountable  Httle  attacks  of  excitement.  The  patient  is 
disinclined  to  amuse  or  employ  himself.  He  looks  on  any 
attempt  to  persuade  him  to  do  so  as  persecution,  and  as  being 
prompted  by  hostile  motives.  There  is  some  depression,  but 
no  intense  mental  pain.  The  patient  associates  with  no  one, 
and  the  kindness  of  relatives  merely  calls  forth  reproaches. 
If  the  patient  lives  long  he  becomes  more  silent  and 
apparently  demented,  but  he  can  always  be  roused  out  of 
this  for  a  short  time.  Complete  typical  dementia  does  not 
usually  occur.  If  there  is  any  tendency  to  periodicity,  the 
remissions  and  aggravations  are  not  regular  or  complete. 
Bodily  he  cannot  be  fattened,  he  looks  sallow  and  haggard, 
his  circulation  is  poor,  his  pulse  weak,  and  anything  hke  a 
healthy  nervous  or  nutritive  tone  is  absent.  There  is  no 
muscular  energy,  and  a  strong  disinclination  to  exertion.  The 
appetite  is  poor  and  capricious.  Colds  are  taken  very  easily. 
The  patients  lose  weight,  and  are  all  round  worse  in  cold 
weather.  The  temperature  tends  to  be  low  until  the  lungs 
become  affected,  and  then  there  is  an  insidious  evening  rise 
which  is  perhaps  the  only  sign  of  the  presence  of  a  bodily 
disease.  In  very  many  of  the  cases — one-half  the  number, 
according  to  my  experience — the  chest  symjDtoms  are  at  first 
latent,  even  after  the  lungs  have  become  markedly  affected. 
There  is  no  cough  or  spit  or  pain.  I  have  often  happened  to 
notice  that  a  patient  labouring  under  phthisical  insanity — and 
this  apphes  to  cases  of  dementia  and  many  cases  of  acute 
insanity  too — was  breatliing  a  little  more  quickly  than  normal, 
or  was  looking  more  pinched,  or  was  falling  off  his  food,  or 
his  pulse  was  quicker  and  weaker  than  usual,  or  that  he  had  a 
hectic-looking  spot  on  one  cheek,  or  that  his  skin  felt  hot;  and, 
on  examining  the  chest  in  consequence  of  some  such  indication, 


PHTHISICAL   INSANITY.  511 

I  have  found  extensive  consolidation,  or  breaking  up  of  the 
lung  tissues.  The  progress  of  the  lung  disease  varies  much 
in  diffc^rent  cases,  in  some  being  rapid  and  causing  death  in  a 
few  months,  and  in  others  going  on  for  years  if  the  conditions, 
food,  and  hygiene  are  favourable.  I  have  seen  such  cases  in 
the  very  feverish  stage  before  death,  when  the  temperature 
rose  over  102°,  rouse  up  wonderfully,  and  even  cease  to  mani- 
fest the  morbid  suspicions,  but  such  cases  are  exceptional. 
It  would  seem  as  if  in  these  cases  the  high  temperature  and 
quickened  circulation  stimulated  the  anaemic  and  ill-nourished 
convolutions  to  increased  and  almost  normal  mental  activity. 

The  following  is  an  example  of  the  disease  : — 

J.  N.,  aet.  43.  Her  previous  history  was  not  known  very 
accurately,  but  this  seems  to  have  been  the  first  attack  of 
insanity,  and  it  had  not  existed  more  than  a  few  months. 
She  resided  in  London,  and  came  to  Edinburgh  to  seek  her 
son,  who  had  been  dead  some  time.  This  she  had  known 
before  she  became  insane.  No  hereditary  predisposition  was 
known.  She  had  been  wandering  about  and  troublesome, 
but  not  violent. 

On  admission  she  was  apathetic,  and,  when  roused,  sus- 
picious-looking, not  answering  questions  correctly  or  even 
intelligently,  but  showing  her  insanity  much  more  by  her 
pecuhar  expression  of  face  and  her  conduct  when  spoken  to 
than  by  her  conversation.  Hair  dark,  complexion  dark. 
She  is  of  the  melancholic  temperament.  She  was  on  ad- 
mission thin  and  weak,  but  appeared  before  becoming  insane 
to  have  enjoyed  good  bodily  health  on  the  whole. 

After  being  some  months  in  the  Asylum,  her  mental  state 
was  as  follows  : — 

"  She  has  many  delusions,  which  she  only  shows  at  times, 
and  is  not  very  consistent  in  her  expression  of  them.  She 
fancies  that  she  is  pregnant,  that  the  foetus  is  extra-uterine, 
and  that  she  will  require  to  be  operated  upon.  She  is  very 
suspicious,  especially  of  her  food,  sometimes  starving  herself 
through  fear  of  being  poisoned.     She  also  at  times  seems  to 


512  PHTHISICAL   INSANITY. 

imagine  that  slie  has  much  property  that  is  being  kept  av/ay 
from  her.  She  is  very  idle,  and  cannot  by  any  means  be 
persuaded  to  employ  herself.  At  times,  without  any  cause, 
she  becomes  abusive  to  those  about  her,  and  much  excited. 
She  remains  tliin  and  pale,  but  takes  her  food  well,  and  has 
shown  no  clear  symptoms  of  suffering  from  any  actual  lung 
disease.  She  is  unsociable,  takes  no  interest  in  her  friends, 
does  not  Avant  to  get  away  from  the  Asylum,  or  at  least  ex- 
presses no  AA"ish  to  do  so.  She  gets  excited  for  short  periods 
of  a  few  hours  at  times,  and  during  these  attacks  of  excite- 
ment all  her  symptoms  are  much  Avorse." 

And  in  the  course  of  two  years  her  state  was  the  follow- 
ing :— 

She  is  now  much  thinner  and  weaker  than  she  was,  but  no 
marked  symptoms  of  any  disease  have  manifested  themselves, 
and  she  refuses  to  alloAv  any  examination  to  be  made  of  her 
chest.  She  is  more  taciturn  and  less  seldom  abusiA^e,  except 
Avhen  she  is  spoken  to  or  interfered  with.  She  never  speaks 
to  any  one,  except  to  ask  for  something  she  wants,  resents 
being  interfered  with  in  any  way,  and  treats  all  about  her  as 
if  they  were  her  enemies.  "When  asked  about  her  health  she 
frequently  becomes  abusive,  and  seems  to  think  some  insult 
or  harm  is  meant  her.  She  is  never  pleasant  by  any  possi- 
bility, and  never  thankful  for  any  attention  shown  her.  She 
distinguishes  in  no  way  those  who  are  kind  to  her  from  those 
Anth  Avhom  she  has  nothing  to  do.  At  long  intervals  now 
she  becomes  excited,  abusive  to  some  one  who  has  given  no 
cause  for  such  conduct,  and  she  assigns  no  reason  for  such 
abuse. 

She  remained  mentally  as  described,  but  in  bodily  health 
became  weaker,  lost  flesh,  and  did  not  take  her  food  so  well, 
but  no  cough  nor  spit  appeared  till  two  months  before  her 
death,  AA-hich  occurred  after  she  had  been  in  the  Asylum  five 
years.  For  two  or  three  years  before  death  she  had  been 
thin,  pale,  weak,  capricious  in  her  appetite,  inclined  to  keep 
her   bed,    and    evidently   labouring    under    organic    disease. 


PHTHISICAL   INSANITY.  513 

She  resisted  an  examination  of  her  chest  so  very  strongly 
that  it  was  never  thoroughly  made.  There  was  never  any 
diarrhcea,  but  all  the  other  symptoms  of  phthisis  were  present 
in  great  severity  for  two  months  before  death. 

Post-mortem  Examination.  —  The  brain  was  atrophied, 
anaemic,  and  oedematous.  The  white  substance  composing 
and  surrounding  the  fornix  and  septum  lucidum  was  almost 
diffluent.  The  left  lung  was  everywhere  infiltrated  with 
masses  of  tubercle,  each  tubercular  spot  soft  in  the  centre. 
The  cavities  so  formed  were  many  of  them  evidently  very 
old.  The  upper  lobe  of  the  right  lung  was  in  a  similar  condi- 
tion. The  mesenteric  glands  were  enlarged  and  tubercular. 
The  mucous  membrane  of  the  caecum  and  ascending  colon 
was  ulcerated,  thickened,  and  red. 

Commentary  on  such  a  case  is  almost  superfluous  after 
what  I  have  said  about  phthisical  insanity.  A  woman  has 
a  family,  and  lives  till  she  is  43.  She  then  becomes  insane, 
never  having  very  acute  symptoms,  suspicion,  irritability, 
unsociability,  with  causeless,  unaccountable  exacerbations,  and  a 
want  of  interest  in  anything  being  the  chief  symptoms.  She  is 
thin  and  in  weak  bodily  health  when  she  becomes  insane,  and 
although  having  good  food  and  fresh  air  never  gets  stronger. 
She  becomes  weaker,  paler,  and  thinner  gradually,  until 
she  is  exhausted  and  very  weak,  and  then  a  severe  cough 
and  spit  comes  on  two  months  before  she  dies.  Can  any  one 
doubt  that  in  this  case  the  insanity  was  contemporaneous  in 
its  appearance  with  the  preliminary  symptoms  of  tuberculosis, 
that  the  ordinary  symptoms  of  the  latter  disease  were  obscured 
by  the  state  of  the  brain,  and  that  it  was  the  tuberculosis,  and 
not  the  insanity,  that  kept  the  patient  thin  and  weak  bodily  ? 
And  do  not  the  mental  symptoms  resemble  in  some  degree 
those  of  an  exhausted  man  whose  brain  has  been  starved 
of  a  suflicient  supply  of  nourishment  by  a  disabled  stomach, 
an  exhaustive  discharge,  or  unsound  lungs. 

The  following  is  an  example  of  phthisical  insanity  beginning 
as  monomania  of  suspicion. 

2  K 


514  PHTHISICAL  INSANITY. 

J.  0.,  aet.  31,  a  joiner.  Father  had  been  insane.  Had 
led  a  dissipated  life  at  times.  Had  always  made  his  Hving 
at  his  trade.  Was  married,  and  had  a  family.  The  first 
symptoms  of  insanity  were  noticed  more  than  a  year  ago, 
and  he  was  then  sent  to  an  asylum,  but,  having  apparently 
quite  recovered,  he  was  discharged.  He  was  never  quite 
well  after  this,  however.  He  was  unsettled,  would  not  work 
at  his  trade  with  any  one  master  for  more  than  a  few  weeks 
at  a  time.  He  accused  his  wife  of  poisoning  him,  of  conspir- 
ing against  him,  and  of  getting  her  relations  also  to  plot 
against  his  life.  His  having  been  in  an  asylum  at  all  he 
attributed  entirely  to  their  desire  to  get  rid  of  him  for  their 
own  purposes. 

On  admission  into  the  Asylum  he  was  generally  quiet, 
reserved,  and  suspicious  in  look  and  manner,  without  showing 
much  suspicion  in  his  words.  He  was  a  man  in  average 
health,  with  a  fair  complexion,  dark  brown  hair,  and  a  more 
than  usually  intelligent  face.  He  was  very  reticent  about  his 
delusions. 

For  some  time  after  admission  he  wrought  in  the  joiner's 
shop,  but  then  began  to  fancy  that  his  working  there  kept 
him  in  the  Asylum,  and  refused  to  work  any  longer.  He 
became  more  unreserved  in  his  expressions  of  disHke  and  sus- 
picion of  his  wife  and  her  relations.  He  might  often  be  seen 
to  exchange  his  own  dish  for  that  of  his  next  neighbour  at 
meals,  when  he  could  do  so  without  attracting  much  atten- 
tion. He  looked  as  if  he  "  knew  all  about  it "  when  asked 
about  this  proceeding,  but  would  give  no  explanation  of  it. 
He  evidently  had  strong  prejudices  against  the  head  male 
attendant,  and  shook  his  head  and  laughed,  and  said,  "  You 
know  very  well,"  when  asked  why  he  dishked  this  man.  At 
one  time  he  became  so  well  that  his  discharge  from  the 
Asylum  was  contemplated. 

He  had  not  been  in  the  Asylum  six  months  till  he  had 
slight  haemoptysis,  and  when  his  chest  was  examined  the 
presence  of  tubercular  disease  was  indicated   by  dulness  on 


PHTHISICAL  INSANITY.  515 

percussion,  and  crepitation  on  auscultation  at  the  apices  of 
both  kings.  He  said,  however,  that  he  had  often,  before  he 
came-  into  the  Asyhim,  spat  blood.  Shortly  afterwards  his 
condition  was  the  following  : — 

A  year  after  admission  he  was  attacked  with  a  cough  and 
spit,  and  his  difficulty  of  breathing  became  increased,  and  he 
was  no  longer  asked  to  do  any  work.  He  got  much  worse 
mentally  immediately  after  he  was  allowed  to  be  quite  idle. 
He  could  never  be  induced  to  take  any  kind  of  medicine  for 
more  than  a  day  or  two,  and  the  extra  diet  and  stimulants 
ordered  for  him  were  almost  forced  down  his  throat.  The 
lung  disease  advanced  rapidly.  He  became  worse  every 
week,  wliile  his  suspicions  and  irritability  became  the  cause 
of  more  and  more  misery  to  him.  He  gasped  reproaches 
against  the  medical  officer,  as  he  sat  coughing  and  breathless, 
for  giving  him  the  medicines  intended  to  relieve  him.  Every- 
thing that  was  done  for  him  he  imagined  to  be  for  a  sinister 
purpose,  every  one  who  was  kind  to  him  he  suspected  of 
being  an  enemy,  and  all  the  symptoms  of  lus  disease  he  be- 
heved  to  be  caused  by  his  food  or  medicine.  All  his  symptoms 
were  as  severe,  when  they  once  had  fairly  commenced,  as  in 
ordinary  cases  of  phthisis  among  the  sane. 

To  the  last  he  retained  his  delusions  unchanged.  He  died 
witliin  eighteen  months  from  the  time  of  his  admission.  He 
was  much  exhausted,  but  not  quite  emaciated  when  he  died. 

Post-mortem  Examination. — The  brain  was  on  the  whole 
almost  normal,  except  that  the  arachnoid  was  very  milky, 
and  the  pia  mater  infiltrated  with  opaque  serum,  while  the 
lining  membranes  of  the  ventricles  were  thickened  and,  in 
the  anterior  part  of  the  lateral  ventricles,  covered  with  small 
granulations. 

The  lungs  were  both  almost  entirely  infiltrated  with 
tubercle.  This  tubercle  was  very  hard,  however,  except  in 
some  softened  spots.  It  was  intermixed  with  the  fibrous 
pneumonic  lung,  and,  as  was  seen  from  the  appearance  of 
some  of  the  vomicse,  as  well  as  the  consolidated  fibrous  lung. 


516  PHTHISICAL  INSANITY. 

the  organ  had  been  affected  for  a  long  time.  The  cavities 
and  the  densest  parts  of  the  tubercular  deposit  in  both  lungs 
were  at  the  bases.  There  was  no  ulceration  of  the  caecum  or 
colon. 

This  is  a  good  example  of  those  cases  of  monomania  of  sus- 
picion, almost  all  of  whom,  according  to  my  statistics,  die  of 
tuberculosis.     The  insanity  was  strongly  hereditary. 

The  Relatioiishij:)  of  PMliisis  and.  Insanity. — Such  are  the 
main  and  typical  features  of  phthisical  insanity,  and  the 
foregoing  are  good  examples  of  the  disease.  Certain 
general  questions  arise  in  regard  to  it  for  answer.  Are  all 
cases  where  we  have  phthisis  among  the  insane  apt  to  be  of 
the  mental  type  I  have  described  ?  I  think  chiefly  those  who 
have  had  the  well-known  bodily  symptoms  of  the  pre-tuber- 
cular  stage  of  phthisis.  The  most  marked  cases  are  those 
with  a  hereditary  tendency  to  both  phthisis  and  to  insanity, 
or  to  the  neuroses.  It  is  surprising  how  often  both  diseases 
occur  in  different  members  of  the  same  family.  Xo  physician 
in  extensive  practice  but  has  met  with  very  many  such 
families.  They  are  too  frequent  to  be  a  mere  coincidence. 
The  constitutional  weakness  which  tends  to  end  in  phtliisis  is, 
I  have  no  doubt,  akin  in  some  degree,  under  some  conditions, 
to  that  which  tends  to  end  in  insanity.  If  one  function  of 
the  braia  is  to  govern  the  trophic  processes  of  the  body,  and 
if  that  organ  is  strongly  predisposed  to  go  wrong  in  its  mental 
functions  in  any  case,  it  stands  to  reason  that  the  law  of 
the  solidarity  of  action  of  the  whole  organ  will  come  in,  and 
that  the  nutritive  processes  will  often  be  affected  also  in  that 
person,  and  the  recuperative  and  resistive  power  lessened. 
Daily  experience  among  the  insane  shows  us  that  this  is  so. 
As  I  said  when  speaking  of  the  nature  and  treatment  of 
melanchoHa,  thinness  is  its  bodily  essence  and  almost  constant 
accompaniment,  and  fatness  its  natural  cure.  So  in  regard 
to  that  special  tendency  to  depraved  or  weakened  tropliic 
energy  that  speedily  tends  to  end  in  lung  disease  :  if  it  is  not 
cured  it'  tends  to  affect  the  nutrition  of  the  brain,  and  the 


PHTHISICAL  INSANITY.  517 

result  is  phthisical  insanity.  Ascertainable  hereditary  predis- 
position to  insanity  exists  in  7  per  cent,  more  of  the  cases  of 
phthisical  insanity  than  in  the  insane  generally. 

Which  disease  begins  first  ? — The  insanity  in  most  cases, 
undoubtedly.  In  some  instances  it  exists  several  years  before 
any  discoverable  lung  trouble  appears,  just  as  there  are  many 
persons  who  have  all  the  premonitory  symptoms  of  phtliisis 
long  before  the  lungs  are  affected.  I  am  not  now  entering 
into  the  question  of  the  different  forms  of  phthisis,  or  the 
modes  in  which  the  lungs  are  affected,  or  into  the  specific 
germ  theory  of  tubercle.  By  the  phthisis  I  speak  of,  I  mean 
that  typical  form  where  there  has  been  a  marked  consti- 
tutional tendency  to  malnutrition  and  lung  disease, — that 
form,  in  short,  which  is  usually  hereditary,  and  always  has 
far  more  symptoms  than  the  mere  lung  disease  to  characterise 
it.  The  mode  and  time  at  which  the  lungs  are  affected  by 
actual  disease  are  accidents  due  to  special  circumstances, 
such  as  exposure  to  cold  or  to  infection  by  bacilli. 

In  regard  to  the  question  whether  insanity  is  not  some- 
times cured  by  the  advent  of  lung  disease,  I  confess  I  have 
never  seen  any  real  instance  of  it.  I  have  seen  many  cases 
where  patients  brightened  up,  and  were  less  melancholic  and 
far  less  torpid  after  the  temperature  rose  through  aggravation 
of  lung  disease,  and  I  have  seen  this  occur  repeatedly  in  the 
same  case  as  the  inflammatory  process  became  active.  But 
the  improvement  was  only  apparent,  and  was  always  transi- 
tory. It  simply  resulted  from  the  increased  temperature 
and  more  active  circulation  in  the  brain.  Any  disease  that 
produces  those  conditions  will  have  the  same  effect. 

A  very  interesting  question  arises  as  to  the  effect  of  phthisis 
on  the  mental  condition  of  sane  persons.  There  is  the  uni- 
versally recognised  spes  phthisica,  and  there  is  often  also  a 
mental  brilhancy,  short  and  fitful  like  the  light  of  an  ill- 
supplied  lamp,  and  there  are  delirious,  letbargic,  and  con- 
fused times,  in  diflferent  cases.  In  very  many  there  is  a 
fancifulness,  a  causeless  changing  from  hope  to  despondency, 


518  PHTHISICAL   INSANITY. 

an  incapacity  for  continuons  tlioiight,  that  seems  to  cliaracter- 
ise  this  disease  more  than  other  chronic  aihnents.  Doctors 
do  not  see  these  things  so  much,  for  at  their  visit  the  patients 
pick  themselves  up  mentally  ;  but  ask  nurses  and  relatives  who 
are  with  such  persons  all  the  time,  and  they  will  tell  you  of 
the  many  small  mental  peculiarities  of  sane  phthisical  patients. 

Statistics. — In  order  to  exhibit  the  results  of  my  experience 
in  regard  to  phthisical  insanity  for  the  nine  years  1874-82 
inclusive,  in  a  statistical  form,  I  have  gone  carefully  through 
the  Case-Books  of  the  Eoyal  Edinburgh  Asylum.  Each  case 
was  diagnosed  as  to  its  clinical  mental  type  within  the  year 
of  its  admission.  This  is  perhaps  too  soon  in  this  form  of 
insanity,  for,  as  I  mentioned,  some  of  the  patients  have  a 
regular  maniacal  or  melancholic  attack  to  begin  with,  of  short 
duration.  The  general  result  was  this : — During  those  nine 
years  there  have  been  3145  admissions.  Of  those,  85  have 
been  diagnosed  as  phthisical  insanity.  This  is  2*7  per  cent, 
of  the  cases  admitted.  Following  out  these  85  cases,  I  find  that 
26  have  been  discharged  recovered  in  mind.  This  is  a  recovery 
rate  of  30  per  cent.  The  recovery  rate  in  the  Asylum  during 
the  same  period  has  been  46  per  cent.  This  would  show, 
supposing  my  diagnosis  to  have  been  correct,  that  cases  of 
phthisical  insanity  recover,  but  in  much  less  proportion  than 
the  average  of  patients  sent  to  the  Asylum,  which  include, 
it  must  be  remembered,  many  general  paralytics,  paralytics, 
dements,  and  other  cases  hopeless  from  the  beginning.  The 
recovery  rate  among  the  patients  admitted  with  no  recognis- 
able organic  brain  disease,  and  who  had  been  less  than  a 
year  insane  before  admission,  was  about  70  per  cent.  "We 
may  say,  therefore,  that  the  cases  diagnosed  as  phthisical 
insanity  recover  in  much  less  than  half  the  proportion  of 
cases  of  insanity  uncomplicated  with  brain  disease.  In  order 
that  this  proportion  of  phthisical  insanity  should  recover, 
special  treatment — dietetic,  moral,  and  medicinal — is  required 
to  combat  the  depraved  general  and  brain  nutrition  present. 

I  next  inquired  into  the  death-rate  from  tubercular  com- 


PHTHISICAL  INSANITY.  519 

plaints  among  tlie  85  plithisically  insane  patients.  Up  to 
this  time  18  have  died  of  phthisis,  but  it  must  be  taken  into 
account  that  in  addition  to  the  26  who  recovered  there  were 
32  cases  removed  from  the  institution  not  recovered  mentally, 
some  of  these  being  taken  home  to  be  nursed  by  their 
relations  during  their  last  illness — to  die,  in  short.  But 
more  than  the  18  will  die  of  phthisis,  for  those  admitted  in 
the  recent  years  have  not  yet  had  time  for  the  complaint  to 
develop,  and  some  of  them  are  now  phthisical.  The  general 
result  is  that  18  out  of  the  27  who  were  not  recovered  or 
removed  have  already  died  of  phthisis. 

I  next  examined  into  the  general  statistics  of  phthisis  in 
the  institution,  quite  apart  from  phthisical  insanity,  for  the 
same  period  of  nine  years.  Eighty-three  cases  died  of  this 
disease  in  that  time.  There  having  been  altogether  613 
deaths  in  the  time,  this  was  at  the  rate  of  13  "5  per  cent.,  or 
one  in  seven.  Of  all  the  deaths  from  phthisis,  therefore, 
21  "7  per  cent.,  or  just  over  one  in  five,  had  been  originally 
diagnosed  as  phthisical  insanity.  Looking  at  the  patients 
suffering  from  the  other  cHnical  forms  of  insanity  who  died  of 
phtliisis,  none  of  them  approach  in  number  the  phtliisical 
insanity.  Seven  cases  of  epileptic  insanity  died  of  phthisis 
and  seven  cases  of  general  paralysis — though  the  number  of 
this  disease  who  died  of  phthisis  I  think  is  much  more  than 
the  average — and  five  cases  of  adolescent  insanity.  Beyond 
these  no  special  variety  was  found  in  the  phthisical  list. 

In  going  over  those  patients  who  had  died  of  phthisis  I  had 
an  opportunity  of  seeing  a  clinical  fact  in  regard  to  the  efi'ect, 
on  one  or  two  cases,  of  the  development  of  phthisis  on  a  pre- 
viously existing  insanity  of  long  duration.  In  such  patients 
it  often  had  the  effect  of  producing  a  mental  condition  similar 
to  the  symptoms  of  phthisical  insanity,  they  not  having 
laboured  under  such  mental  symptoms  before.  Such  patients 
became  suspicious,  sullen,  irritable,  and  unsocial,  some  of  them 
being  also  melancholic.  One  young  man,  J.  P.,  who  had 
been  a  cheerful,  active  fellow,  sociable,  constantly  playing  the 


520  PHTHISICAL   INSANITY. 

piano  and  singing,  became  moody,  suspicious,  impulsive,  and 
irritable  just  before  his  chest  was  found  to  be  aflFected,  and  while 
he  was  getting  thin,  not  taking  his  food,  and  looking  ill. 

The  certainty  which  now  exists  that  tuberculosis  is  always 
due  to  infection  by  its  specific  bacillus  does  not  in  any  way 
alter  my  facts  and  conclusions  as  to  the  connection  of  phthisis 
and  insanity,  and  the  existence  of  a  specific  form  of  insanity 
that  may  properly  be  called  phthisical.  For  all  pathologists 
agree  that  it  is  not  the  presence  of  the  specific  bacillus  alone, 
for  it  must  be  present  more  or  less  everywhere  at  times,  but 
the  condition  of  the  organism  that  determines  whether  the 
bacilli  find  a  fitting  nidus  for  their  propagation,  and  the  evil 
results  to  the  organism  of  infection,  are  proved  to  arise  from 
the  ptomaines  generated  by  the  microbes,  and  not,  strictly 
speaking,  from  the  microbes  themselves.  These  poisonous 
ptomaines  circulating  in  the  blood  and  reaching  the  brain 
cortex  will  be  Hkely  to  disturb  its  action,  especially  in  cases 
where  there  is  an  inherited  tendency  towards  insanity,  or 
towards  neurotic  diseases. 

There  is  another  element  to  be  taken  into  consideration  in 
the  question  of  the  connection  between  tuberculosis  and  in- 
sanity. It  is  this.  To  a  considerable  extent  they  are  both 
very  apt  to  attack  the  organism  during  the  period  of  develop- 
ment. 'Now  it  may  be  taken  as  a  law  which  is  of  universal 
apphcation  that  "  any  tissue  or  organ  that  is  abnormally  non- 
resistive  to  disease  may  be  considered  not  to  have  attained 
maturity — being  in  a  condition  of  non-development,  or  arrested 
development — or  to  have  undergone  retrogression,  temporary 
or  permanent."  ^  Tuberculosis  in  all  its  forms  is  much  more 
common  before  the  age  of  25,  which  may  be  taken  as,  on  an 
average,  the  age  of  completed  development,  and,  as  we  shall 
see,  there  is  a  very  important  and  frequent  form  of  insanity — 
adolescent  insanity — which  coincides,  in  regard  to  the  age  it 
occurs,  with  pulmonary  consumption,  i.e.,  they  both  occur 
most  frequently  between  the  ages  of  20  and  25. 
^  The  Neuroses  of  Development,  by  the  author,  p.  5. 


LECTURE   XIV. 

UTERINE  OR  AMENORRHCEAL  INSANITY. 

Disorders  of  menstruation  and  their  relationship  to  insanity,  two  kinds 
of  insanity  resulting — Acute  Mania  and  Melancholia — Symptom  or 
cause  ? 

No  doubt  the  influence  of  woman's  great  function  of  men- 
struation is  considerable  on  her  normal  mentalisation.  It  has 
a  psychology  of  its  own,  of  which  the  main  features  generally 
are  a  shght  irritability  or  tendency  towards  lack  of  mental 
inhibition  just  before  the  process  commences  each  month,  a 
sHght  diminution  of  energy  or  tendency  to  mental  slowness 
and  depression  during  the  first  day  or  two  of  its  continuance, 
and  a  very  considerable  excess  of  energising  power  and  sus- 
ceptibility of  feeUng  during  the  first  week  or  ten  days  after 
it  has  entirely  ceased,  the  last  phase  being  coincident  with 
woman's  period  of  highest  conceptive  power  and  keenest 
generative  nisus.  As  is  well  known  to  all  physicians,  many 
purely  nervous  derangements  and  diseases,  such  as  neuralgia, 
migraine,  epilepsy,  and  chorea,  are  apt  to  be  aggravated  at 
the  menstrual  periods  or  to  begin  then.  There  are  often  per- 
versions of  the  great  instincts  and  appetites  then.  In  some 
women  the  social  instincts  are  then  partly  suspended,  and  in 
others  there  are  perversions  of  the  appetites  for  food  and 
drink.  Dr  Halliday  Croom  has  kindly  given  me  the  notes 
of  two  such  cases.  One  young  lady  patient  of  his  at  every 
menstrual  period  pulls  out  and  eats  the  bristles  of  the  hair 
brushes  in  her  own  room,  and  sometimes  goes  into  other  rooms 
for  more  brushes  for  the  same  purpose.  He  has  another  lady 
patient,  married,  set.  .36,  who  for  fifteen  years  has  eaten,  at 


522  UTEKINE   OR   AMENORRHCEAL  INSANITY. 

each  menstrual  period,  salt,  dry  oatmeal,  and  bits  of  sponge, 
and  has  been  none  the  worse  for  this.  I  have  met  with — 
and  what  physician  has  not? — cases  of  women  who  had 
intense  cravings  for  stimulants  and  narcotics  at  each  menr 
strual  period,  and  indulged  those  cravings,  to  their  intense 
disgust  and  regret  afterwards.  Dr  Croom  gives  me  the  notes 
of  a  case  where  the  craving  was  for  malt  liquors  only. 

The  regular  normal  performance  of  the  reproductive 
functions  is  of  the  highest  importance  to  the  mental 
soundness  of  the  female.  Disturbed  menstruation  is  a 
constant  danger  to  the  mental  stability  of  some  women ; 
nay,  the  occurrence  of  normal  menstruation  is  attended 
with  some  risk  in  many  unstable  brains.  The  actual  out- 
break of  mental  disease,  or  of  its  worst  paroxysms,  is  coin- 
cident with  the  menstrual  period  in  a  very  large  number 
of  women  indeed.  It  does  not  follow  from  this,  of  course, 
that  the  menstruation  caused  the  insanity  in  all  such  cases. 
The  constant  difficulty  the  physician  has  is  to  know  whether 
the  disordered  or  suspended  menstruation  is  a  cause  or  a 
symptom.  ]S"early  all  the  acute  varieties  of  insanity  tend  to 
disturb  or  suspend  menstruation  in  women  while  the  acute 
symptoms  last.  I  find  that  attendants  on  the  insane  do  not 
expect  menstruation  to  be  regular,  if  present  at  all,  in  cases 
of  acute  mania  or  of  intensely  excited  melancholia.  I  also 
find  that  among  the  women  patients  in  an  asylum,  taking 
them  throughout,  chronic  and  acute,  the  occurrence  of 
menstruation  is  apt  to  cause  an  aggravation  of  the  morbid 
mental  symptoms  present.  The  melanchohcs  are  more 
dejDressed,  the  maniacal  more  restless,  the  delusional  more 
under  the  influence  of  their  delusions  in  their  conduct ; 
those  subject  to  hallucinations  have  them  more  intensely,  the 
impulsive  cases  are  more  uncontrollable,  the  cases  of  stupor 
more  stupid,  and  the  demented  tend  to  be  excited.  In  the 
chronic  insane,  whose  home  the  asylum  is,  and  its  regulations 
and  routine  their  rules  of  life,  we  frequently  find  the  men- 
strual  period   a   time   when  their  subjection  to  the  asylum 


UTERINE   OR   AMENOKRHCEAL   INSANITY.  523 

discipline  is  not  so  absolute  as  usual,  and  their  conformity 
to  the  ways  of  its  daily  life  is  not  so  unvarying.  Of  course 
thepce/uxe  a  great  many  exceptions  to  this  in  the  chronic 
insanity  of  women  to  whom  the  menstrual  period  makes  no 
difference  whatever.  Those  are  usually  patients  affected  by 
quiet  mild  dementia,  who  work  hard  and  are  in  good  bodily 
health.  At  times  we  see  special  directions  taken  by  those 
menstrual  aggravations  of  mental  disease,  such  as  an  accentua- 
tion of  the  emotional  perversions  that  exist,  an  excitation  of 
the  amatory  feelings  towards  the  opposite  sex,  or  a  feeling  of 
sexual  repulsion,  a  stimulation  of  the  habit  of  masturbation, 
or  the  occurrence  of  stupor  and  confusion  in  the  whole  of 
the  mental  processes.  Stupor  is  exceedingly  apt  to  occur  in 
.insane  young  women  during  adolescence  about  their  menstrual 
times,  I  have  now  a  patient,  J.  Q.,  of  19,  usually  a  bright 
active  girl,  who,  for  about  a  week  or  ten  days  at  her  men- 
strual periods,  becomes  confused,  stupid,  and  depressed — 
her  face  and  whole  muscular  movements  showing  an  extreme 
hebetude  and  slowness.  Some  few  melancholic  patients  get 
maniacal  at  the  menstrual  periods ;  and  I  have  seen  a  case 
of  acute  mania  cease  to  be  excited  and  become  depressed  and 
fearful  during  menstruation. 

Taking  the  mass  of  the  more  chronic  and  quiet  cases  of 
insanity,  I  find  that  menstruation  is  just  about  as  regular 
as  to  time,  and  as  normal  in  the  amount  of  discharge,  as 
among  a  similar  number  of  average  sane  women.  A  very 
considerable  number  of  female  lunatics  have  the  delusion 
that  they  are  occasionally  ravished  by  men  at  night,  and 
in  such  cases  this  fancy  is  usually  more  intense  after  men- 
struation. 

But  apart  from  those  general  effects  on  all  kinds  of  existing 
mental  disease  of  disordered  or  suspended  menstruation,, 
insanity  in  some  few  cases  actually  results  de  novo  from  this 
as  an  exciting  or  predisposing  cause.  Those  cases  may  be 
conveniently  termed  uterine  or  amenorrhoeal  insanity.  Most 
of  them,  two-thirds  at  least,  are  melancholic  in  character,  the 


524  UTERINE   OK   AMENOKRHCEAL   INSANITY. 

mental   symptoms   following   the   amenorrhoea,    and  passing 
away  wlien  regular  menstruation  returns. 

Tlie  folloiving  is  a  typical  case  of  amenorrhoeal  insanity : —  . 
J.  E.,  set.  20,  of  a  neurotic  but  not  an  insane  heredity. 
Comes  of  an  "  excitable  "  family.  Had  gone  from  a  country 
district  and  farm  work  to  domestic  service  in  a  city,  where, 
after  a  year  or  two,  she  fell  off  in  general  health,  and  ceased 
to  menstruate.  She  at  once  became  depressed,  took  morbid 
and  distressing  views  of  rehgion,  was  forgetful,  confused,  and 
sleepless,  and  lost  her  appetite.  She  wept  without  cause ; 
was  very  obstinate,  misinterpreting  the  object  of  our  giving 
her  medicine,  making  her  work,  walk,  and  keep  herself  tidy. 
She  said  she  should  be  out  of  the  world  and  was  not  fit  to 
Hve,  but  never  attempted  suicide.  She  was  ordered,  and 
made  to  take,  iron  and  aloes,  with  much  fresh  air  and 
fattening  diet.  She  got  worse  at  first,  and  hallucinations 
of  hearing  developed.  She  distinctly  heard  voices  teUing  her 
she  was  the  worst  person  alive.  She  would  have  refused 
food  had  she  been  allowed  to  do  so.  In  about  two  months 
she  began  to  improve  in  body  and  mind,  especially  in  bodily 
looks  and  weight.  For  three  months  longer  she  remained 
depressed,  and  then  menstruated  after  a  series  of  hot  baths 
and  mustard  to  her  feet.  She  brightened  up  from  the  first 
day  of  menstruation  as  if  a  cloud  had  been  lifted  ofi"  her 
mind,  and  she  has  kept  well  since. 

In  such  a  case  I  do  not  think  it  was  the  amenorrhoea  alone 
which  caused  the  melanchoha.  Both  were  in  reahty  the 
result  of  a  running  down  in  health  and  vitahty  from  a  change 
in  the  conditions  of  Hfe,  but  no  doubt  the  mental  symptoms 
were  aggravated  by  the  suspended  menstrual  function.  I 
do  not  think  the  melancholia  would  have  been  cured  by  a 
restoration  of  menstruation,  had  that  been  possible,  before 
the  blood  had  become  richer  and  the  nutrition  improved. 
In  fact,  I  have  seen  the  coming  on  of  the  menses  under 
those  circumstances  aggravate  the  mental  symptoms,  the 
case  assuming  during  such   menstruation  a   maniacal  form. 


UTERINE   OR   AMENORRHCEAL   INSANITY.  525 

The  treatment  of  such  cases  should  therefore  be  directed 
at  first  towards  improving  the  general  health  more  than 
towaidfi  restoring  menstruation  merely,  at  all  events  until 
the  nutrition  of  the  body  is  improved.  After  that  the  usual 
means  for  restoring  the  menstrual  function  should  be  resorted 
to,  and  when  they  are  successful,  or  when,  as  most  frequently 
happens,  nature  restores  the  function,  the  mental  improve- 
ment is  sometimes  as  marked  and  immediate  as  in  J.  E.'s 
case.  It  will  be  observed  that  some  amount  of  improvement 
took  place  in  her  mental  state  as  the  bodily  nutrition  im- 
proved before  menstruation  returned. 

The  melancholic  cases,  of  which  this  of  J.  E..  is  the  type, 
nearly  all  recover,  in  my  experience.  Out  of  twenty  of  very 
typical  form  which  we  have  had  in  the  Eoyal  Asylum  in  the 
past  nine  years,  eighteen  have  recovered. 

About  one-third  of  the  amenorrhoeal  cases  were  maniacal, 
with  no  melanchoHc  tendency.  Such  cases  were  by  no  means 
so  clearly  connected  with  the  absent  menstruation  as  even 
the  melancholic  ones,  nor  did  they  show  the  same  tendency 
to  recover  in  mind  coincidently  with  its  restoration.  In  fact, 
I  was  by  no  means  so  sure  of  the  same  ^kind  of  direct  con- 
nection  between  the  amenorrhoea  and  the  mental  symptoms 
in  most  of  them  as  in  the  melancholic  cases. 

Sudden  Suppression  of  Menstruation. — It  is  commonly  sup- 
posed that  the  sudden  suppression  of  menstruation  in  a 
young,  full-blooded,  healthy  woman  of  nervous  heredity, 
through  chill  or  shock,  is  very  liable  to  cause  an  outburst  of 
acute  dehrious  mania.  Some  authors  speak  of  this  as  if  it 
were  one  of  the  common  causes  of  insanity.  I^o  doubt  it 
occurs,  but  I  have  not  met  with  more  than  a  few  cases  in 
all  my  experience.  One  was  that  of  J.  S.,  a  girl  of  18, 
stout,  florid,  and  healthy,  who  got  wet  through  and  chiUed 
while  menstruating.  The  flow  suddenly  stopped,  and  at 
once  a  fearful  headache  came  on,  with  maniacal  delirium,  a 
temperature  of  103°,  sleeplessness,  and  very  great  violence. 
A  hot  bath,  with  cold  to  the  head,  and  with  enormous  doses 


526  OVARIAN   INSANITY. 

of  bromide  of  potassium,  borax,  and  ammoniated  tincture  of 
valerian,  frequently  repeated,  had  the  effect  of  diminishing 
the  delirium  and  reducing  the  temperature.  A  condition  of 
semi-stupor  and  confusion,  inactivity  and  listlessness  suc- 
ceeded, and  lasted  for  two  months,  when  the  usual  mental 
health  was  regained,  but  it  was  several  months  before 
menstruation  was  restored.  I  would  say  that  stupor  is  a 
more  common  mental  result  of  suppressed  menstruation  in 
young  women  with  a  nervous  heredity  than  acute  mania. 


OYAEIAN"  INSANITY  ("  OLD  MAID'S  INSANITY"). 

Delusions  of  patients  often  tinctured  by  diseases  or  disordered  function 
ovaries  and  uterus — "Old  Maid's  Insanity." 

There  is  a  somewhat  ludicrous  form  of  insanity  that  Dr 
Skae  called  "  Ovarian,"  or,  more  familiarly  and  more  cor- 
rectly, I  think,  "  Old  Maid's  Insanity."  There  is  really  no 
definite  proof  that  the  ovaries  are  either  disturbed  in  function 
or  diseased  in  structure  in  those  cases,  but  it  consists  no 
doubt  of  a  morbid  transformation  of  the  normal  affectiveness 
of  woman  towards  the  opposite  sex.  The  disease  usually 
occurs  in  unprepossessing  old  maids,  often  of  a  rehgious  hf e, 
who  have  been  severely  virtuous  in  thought,  word,  and 
deed,  and  on  whom  nature,  just  before  or  after  the  climac- 
teric, takes  revenge  fof  too  absolute  a  repression  of  all  the 
manifestations  of  sex,  by  arousing  a  grotesque  and  baseless 
passion  for  some  casual  acquaintance  of  the  other  sex.  whom 
the  victim  beUeves  to  be  deeply  in  love  with  her,  dying  to 
marry  her,  or  aflame  with  sexual  passion  towards  her,  or 
who  has  actually  ravished  her  after  having  given  her  chloro- 
form. ■  Usually  her  clergyman  is  the  subject  of  this  false 
belief.  Out  of  ten  such  cases  which  I  can  recall,  seven  have 
had  clergymen  as  their  supposed  wooers  or  seducers.     In  no 


HYSTERICAL   INSANITY.  527 

case  was  there  the  very  shghtest  possible  ground  for  the 
notion.  In  two  cases  the  ladies  had  never  even  spoken  to 
their  supposed  lovers.  Certain  gestures,  or,  as  in  one  case, 
the  contents  of  the  agony  columns  of  the  newspapers,  were 
sufficient  proofs  to  them  of  their  hehefs.  The  annoyance  to 
which  unfortunate  men  are  subjected  in  this  way  is  often 
extreme.  Lately  a  lady,  J.  T.,  now  a  patient  of  mine,  went 
to  a  grocer's  shop  and  ordered  her  supply  of  groceries  in 
the  name  of  a  clerical  acquaintance,  saying  she  was  his  wife, 
telHng  the  shopman  to  send  the  bill  to  him,  and  this  as  the 
culmination  of  a  series  of  weekly  letters  to  him  of  forty  pages 
each  !  He  endeavoured  to  give  an  adequate  expression  to 
his  feehngs  in  a  letter  I  received  from  him.  I  have  known 
grave  accusations  made  to  ecclesiastical  authorities,  and  the 
beginnings  of  most  injurious  famas  started  by  such  insane 
women.  Such  patients  were  all  of  them  between  35  and 
43,  and  the  reverse  of  sensuous  in  appearance.  Some  of  them 
were  most  estimable,  but  not  attractive,  ladies,  whom  it  was 
impossible  not  to  pity,  the  whole  thing  was  so  contrary  to 
the  tenor  of  their  lives,  and  so  like  a  trick  played  on  that 
higher  being,  which  they  had  always  cultivated,  by  a  lower 
and  more  animal  nature  wliich  they  had  sedulously  repressed. 
None  of  them  altogether  recovered  from  this  sort  of  delusion, 
but  in  two  of  the  cases,  as  they  passed  into  the  senile  period, 
and  after  the  climacteric,  the  notion  became  so  theoretical 
that  they  almost  ceased  to  allude  to  it. 


HYSTEEICAL  Il^SANITY, 

Insanity  engrafted  on  Hysteria  ;  symptoms  of  both  combined  ;  laughing  ; 
crying  ;  incessant  talking  ;  mock  modesty  ;  sexual  and  erotic  ideas  ; 
imaginary  ailments ;  craving  for  notice  ;  masturbation ;  dirty 
habits  ;  letter  of  hysterical  maniac — Occurs  in  1  per  cent,  of  female 
cases  of  insanity  ;  50  per  cent,  recover — Treatment :  Tonics  ;  baths  ; 
occupation  ;   moral   treatment  ;   discipline  ;   anti-spasmodics  ;   bro- 


528  HYSTERICAL   INSANITY. 

miJes  ;  attention  to  female  health  ;  non-stimulating  diet — Complica- 
tions and  combination  of  adolescent,  hysterical  and  masturbational 
insanities. 

Typical  hysteria,  pure  and  simple,  always  has  a  mental 
complication.  The  intellect,  or  the  feelings,  or  the  morals,  are 
always  affected  along  with  the  purely  bodily  functions.  But 
these  mental  symptoms,  not  forming  the  chief  features  of  the 
disease,  or  not  being  of  such  a  nature  as  to  make  the  patient 
irresponsible  or  unmanageable,  were  not  till  lately  reckoned 
as  being  of  the  nature  of  technical  insanity,  at  least  among 
the  rich.  Among  the  poor,  with  no  one  to  look  after  them, 
hysterical  young  women  are  often  enough  sent  to  asylums. 
And  I  have  seen  most  admirable  results  from  this.  The 
principles  of  asylum  life  and  treatment  are  the  very  best 
principles  of  treatment  for  hysteria.  To  put  the  patient  under 
control,  to  give  her  no  harmful  sympathy,  to  make  her  work 
and  walk  out  regularly,  to  improve  her  bodily  health,  are 
always  very  good  for  a  hysterical  girl.  We  have  had  three 
cases  of  almost  typical  hystero-epilepsy,  with-  a  suicidal  ten- 
dency in  two  of  them,  and  general  unmanageabihty  at  home 
in  the  third,  in  addition  to  the  purely  motor  and  other 
symptoms,  sent  to  this  Asylum  within  the  past  few  years,  and 
I  have  not  seen  nor  heard  of  any  home  or  hospital  treatment 
so  effective  as  the  asylum  treatment  proved  to  be  in  these 
girls.^  But  such  patients  are  rare  in  asylums.  The  usual 
type  of  case  classified  as  hysterical  insanity  consists  of  mania 
or  melancholia  in  a  young  woman,  with  one  or  more  of  the 
following  characteristics  well  marked,  viz.,  a  morbid  ostenta- 
tion of  sexual  and  uterine  symptoms,  feigned  bodily  illness 
to  attract  attention  and  secure  sympathy,  marked  erotic 
symptoms  cloaked  by  sometliing  else,  a  morbid  concentration 
of  mind  on  the  performance  of  the  female  functions,  semi- 
volitional  retention  of  urine,  hysterical  convulsions,  a  morbid 
waywardness,  or  ostentatious  and  real  attempts  at  suicide. 

^  Two  of  these  are  recorded  by  Dr  T.   Inglis  in  the  Edinburgh  Medical 
Journal,  December  1878. 


HYSTERICAL  INSANITY.  529 

The  fasting  girls,  the  girls  with  stigmata,  those  who  see  visions 
of  the  Saviour  and  the  saints  and  receive  special  messages  in 
that  way,  the  girls  who  give  birth  to  mice  and  frogs,  some  of 
those  who  fall  into  trances,  and  those  who  live  on  lime  and 
hair,  are  all  cases  of  this  disease. 

Hysterical  symptoms  are  exceedingly  apt  to  occur  in  the 
insanities  of  puberty  and  adolescence  in  women,  and  along 
with  those  symptoms  the  habit  of  masturbation  is  common. 
It  is  sometimes  difficult,  therefore,  to  know  whether  to  classify 
such  cases  as  adolescent,  hysterical,  or  masturbational  insanity. 
AU  one  can  do  is  to  ascertain  if  the  hysterical  symptoms  are 
the  most  marked  and  prominent  features  of  the  case  before 
we  call  it  hysterical  insanity. 

The  following  case  of  hysterical  insanity  fairly  illustintes 
the  general  features  of  the  disease. 

J.  U.,  set.  21,  of  a  nervous  and  excitable  temperament; 
habits  correct.  An  aunt  epileptic.  Had  on  one  occasion  at 
home  a  mild  attack  of  what  must  have  been  subacute  maniacal 
excitement.  The  cause  of  the  present  attack,  which  has  lasted 
for  four  days,  was  a  fright,  which  first  produced  ordinary 
hysterical  symptoms,  and  then  maniacal  symptoms  engrafted 
on  them.  She  shouted  and  screamed,  spoke  of  hearing  God 
speaking  to  her,  and  would  rush  to  the  window  to  jump  out. 
She  imagined  she  was  a  most  important  person,  attitudinised 
and  did  everything  to  attract  attention  to  herself.  Attention 
and  sympathy  were  craved  by  her,  and  if  she  could  not  get 
them  in  one  way  she  tried  another.  She  refused  her  food, 
saying  it  was  poisoned,  but  took  it  rather  than  be  fed  with 
the  stomach-pump.  She  had  monorrhagia,  and  was  most 
minute  and  circumstantial  in  the  details  as  to  her  female 
health.  She  was  tried  with  hyoscyamine,  valerian,  and  mono- 
bromide  of  camphor  with  apparent  benefit;  but  I  considered 
the  greatest  improvement  was  produced  in  her  case  by  disci- 
pline, work,  open-air  exercise,  tonics,  and  good  plain  food  in 
abundance.  She  improved  at  first,  and  once  or  twice  relapsed, 
but  in  two  months  she  recovered  and  was  discharged.     I  do 

2  L 


530  HYSTERICAL   INSANITY. 

not  like  to  keep  hysterical  cases  too  long  in  tlie  Asylum  after 
convalescence  as  a  general  rule,  for  tliey  sometimes  get  too 
fond  of  the  place,  preferring  the  dances,  amusements,  and 
general  KveHness  of  asylum  life,  even  -with  its  restrictions,  to 
the  humdrum  and  hard  work  of  poor  homes. 

The  following  very  characteristic  letter  of  a  maniacal 
hysterical  girl,  J.  Y.,  very  well  illustrates  the  train  of  thoughts 
in  such  a  case  :  ^  — 

"  My  Dear  Mamma, — It  is  time  that  I  leave  to  return  home.  I  have 
been  tremenduoiisly  changed  for  the  better.  I  think  papa  will  be  able 
to  get  me  a  commission  under  Garibaldi  before  long.  There  are  three 
to  whom  I  am  especially  indebted — one  Mr  C,  the  modeller,  the  other 
the  doctor,  a  Eunuch,  who  modelled  me  at  the  fire,  and  attended  on 
me  and  bathed  me.  He  is,  I  am  sure,  a  gentleman,  a  splendid  doctor. 
Could  not  papa  get  hira  into  a  regiment  abroad  ?  And  there  is  the  nurse. 
Could  not  papa  get  him  any  situation  away  from  Morningside  Asylum 
where  I  am  at  present  ?  I  should  like  papa  to  come  for  me  as  soon  as 
possible.  Do  you  remember  the  verse,  "There  are,"  &c.  (12th  verse 
19th  chapter  of  Matthew).  About  Eunuchs  ?  Then  I  beg  to  inform 
you  that  according  to  Scripture  and  my  conscience,  Jessy,  your  cook,  is 
a  man  ;  and  Janet,  the  mad  devil,  is  a  man  ;  and  D.  and  H.,  boys  who 
can  have  children.  Aunt  I.  is  a  man,  and  )"ourself  also,  both  made  of 
men,  and  I  am  a  boy,  made  of  Dr  C.  and  Dr  Z.  Mrs  T.  is  a  man,  made 
of  men.  They  are  very  ignorant  on  this  subject  here  ;  but  as  for  me  it 
is  certain  that  at  least  the  spirits  have  showed  me,  which  Christ  sent 
when  I  was  under  drugs  ;  thej^  showed  me  this.  I  have  at  times  since 
I  came  here  passed  the  shadow  of  death,  and  therefore  am  authorised  to 
speak  in  opposition  to  all  men  and  women,  gentlemen  aud  ladies  who 
oppose  me.  I  am,  I  can  swear,  as  yoii  want  to  know  what  sex  I  belong 
to,  a  mixture  of  a  nymph  and  a  half-man,  half- woman,  and  a  boy,  and 
a  dwarf,  and  a  fairy.  I  know  more  than  my  fellow  mortals,  having 
expired  eleven  times  before  the  time. — I  am,"  &c. 

Our  statistics  of  hysterical  insanity  show  a  good  proportion 
of  recoveries.  In  the  nine  years  187-l:-82  there  were  34 
female  patients  so  classified,  and  of  those  who  were  treated  to 
the  termination  of  their  malady  60  per  cent,  recovered. 

^  "  Morison  Lectures"  for  1873,  by  Drs  Skae  and  Clouston,  Journal 
of  Mental  Science,  vol.  xix.  p.  500. 


THE   INSANITY   OF   MASTURBATION.  53  L 


THE  mSANITY  OF  MASTURBATION. 

Habit  of  masturbation  very  injurious  to  boys  of  neurotic  temperament 
— Masturbation  as  a  symptom  and  complication  of  insanity — 
Characters  of  Insanity  of  Masturbation  ;  self-feeling  ;  introspection  ; 
solitary  habits  ;  perverted  emotionalism  ;  depression  ;  vacillation  ; 
cowardice  ;  suicidal  feelings  ;  maniacal  attacks  ;  impulsive  acts  of 
violence,  ending  in  Dementia  in  26  per  cent,  of  the  cases  ;  bodily 
signs  ;  pains  in  back  ;  pains  in  head  ;  ringing  in  ears  ;  palpitation, 
&c. — Forms  4  "4  per  cent,  of  all  insanity — Treatment:  Tonic,  bracing  ; 
baths  ;  occupation  ;  muscular  exercise  ;  no  local  means. 

Mental  Effects  of  Masturbation. — The  unnatural  gratifica- 
tion of  the  sexual  appetite  through  masturbation,  it  must  be 
admitted,  is  very  common  among  boys  and  lads.  Especially, 
we  believe,  among  lads  of  the  educated  classes,  brought 
together  in  the  somewhat  artificial  if  not  unnatural  Kfe  of 
our  public  schools,  does  it  prevail.  I  believe  that  the  more 
healthy  and  more  stolid  country  lad,  the  son  of  the  farm- 
labourer,  is  not  so  apt  to  indulge  in  this  unnatural  and  dis- 
gusting practice  as  the  son  of  the  professional  man,  supposing 
each  to  be  initiated  in  the  same  way.  Boys  are  taught  the 
habit,  and  begin  to  practise  it,  often  long  before  they  know 
or  can  know  the  real  difference  between  sexual  good  and  evil. 
But  a  healthily  constituted  lad  in  body,  mind,  and  morals 
does  not  tend  to  come  under  its  influence  to  any  very  hurtful 
extent.  His  natural  organic  repugnance  to  it  strengthens  as 
he  grows  up.  If  he  is  fortunate  enough  to  have  a  home,  or 
access  to  family  life,  his  lower  instincts  are  transformed  and 
elevated  into  the  normal  social  instincts,  through  the  grati- 
fication of  which  they  find  a  natural  and  pleasurable  outlet. 

But  the  habit  of  masturbation,  in  certain  other  cases, 
acquires  a  power  that  is  dominating  and  destructive  to  body 
and  mind.  The  causes  of  this  are,  either  an  innate  morbid 
strength  of  the  reproductive  instinct,  or  much  more  frequently 
an  innate  weakness  of  the  controlling  faculties,  or  a  lack 
of    inherent    brain    stability,    or    an    incapacity   of   organic 


532  THE   INSANITY   OF   MASTURBATION. 

repugnance  to  what  is  unnatural,  Sucli  weaknesses  are  apt 
to  occur  in  the  cliildren  of  neurotic  families.  From  the  be- 
ginning the  habit  is  apt  to  take  a  deep  hold  of  such  youths, 
who  practise  it  to  the  point  of  the  exhaustion  of  all  nervous 
energy.  Even  when  tliis  occurs,  and  when  in  a  healthy 
subject  satiety  would  have  caused  disinchnation  and  incom- 
petence, in  the  sort  of  youth  to  whom  I  refer,  the  practice  is 
not  stopped.  The  weaker  and  more  nervous  he  "gets  the 
more  he  indulges  in  his  evil  habit,  till  the  point  of  absolute 
break-down  of  body  and  mind  is  reached.  It  seems  to  get 
possession  of  him  like  an  evil  spirit,  and  to  dull  and  paralyse 
all  his  better  feelings  and  his  natural  instincts.  The  heredity 
and  temperament  are  no  doubt  the  true  explanation  of  the 
opposing  statements  that  are  confidently  made,  on  the  one 
hand,  that  this  habit  seldom  does  much  permanent  harm, 
and,  on  the  other,  that  it  is  the  root  of  most  of  the  evils  of 
boyhood,  and  that  it  ruins  the  constitution  for  life  of  every 
one  who  has  ever  indulged  much  in  it.  Both  statements  are 
so  far  true  of  boys  of  diff'erent  constitutions  and  heredity. 
It  is  somewhat  hke  drinking  to  excess ;  many  persons  can  do 
this  at  times  without  risk  of  dying  the  death  of  drunkards, 
but  others  cannot  do  so  without  that  distinct  risk.  It  is  no 
doubt  true  that  the  restraint  and  management  of  the  repro- 
ductive instinct  give  most  youths  much  trouble,  and,  as 
medical  men,  the  priests  of  the  body  and  the  teachers  of  the 
truths  of  medico-psychology  and  physiology,  we  can  often 
help  them  by  our  counsel  and  our  knowledge.  Unfortu- 
nately our  help  is  too  seldom  called  in.  We  are  about  the 
only  persons  who  can  help  a  youth  to  strike  the  happy 
mean  between  blissful  but  dangerous  ignorance  and  prurient 
suggestive  knowledge.  We  are  the  only  persons  who  can 
judge  from  the  constitution  of  the  particular  individual  how 
much  he  ought  to  know  and  what  risk  he  runs. 

As  a  complication  and  symptom  of  almost  every  form  of 
existing  insanity,  the  habit  of  masturbation  is  lamentably 
common.     The  melancholic,  the  maniacal,  and  the  demented 


THE   INSANITY   OF   MASTURBATION.  533 

patients  are  all  subject  to  its  indulgence.  The  religious 
ecstatics  who  have  direct  intercourse  with  the  Almighty,  and 
the  suicidal  melanchohcs  who  have  committed  crimes  beyond 
redemption, — many  of  such  patients  of  both  sexes  are  mastur- 
bators.  In  fact  it  is,  as  it  might  be  expected  to  be,  a  common 
sign  of  the  loss  of  self-control,  which  is  the  essence  of  mental 
disease.  When  practised  to  excess  by  the  insane,  it  certainly 
tends  to  aggravate  mental  exaltation,  to  intensify  depression, 
to  produce  stupor,  to  lead  directly  towards  mental  enfeeble- 
ment,  and  to  make  impulsive  tendencies  more  violent.  It 
counteracts  the  effects  of  treatment,  it  induces  relapses,  and 
in  some  cases  prevents  the  recovery  of  otherwise  curable 
cases.  Those  bad  results  are  most  frequently  and  clearly 
seen  in  the  adolescent,  hysterical,  puerperal,  epileptic,  and 
congenital  forms  of  insanity,  and,  curiously  enough,  are  not 
always  absent  in  the  climacteric  and  senile  forms.  I  have 
seen  a  senile  melancholic  of  75  suffer  intensely  from  the 
effects  of  the  practice.  In  all  these,  however,  it  is  one  of 
many  symptoms  of  mental  disease.  It  is  not  the  chief 
cause,  nor  is  it  the  chief  symptom  present,  and  it  does 
not  colour  the  cases  so  as  to  give  them  any  distinct  mental 
features. 

There  is  a  special  form  of  mental  disease,  however,  in  which 
masturbation  is  the  chief  cause  of  the  malady ;  it  is  the  chief 
symptom  present,  and  it  gives  the  whole  case  distinct  features. 
This  has  been  named  the  insanity  of  masturbation,  and  has 
several  well-marked  features.  It  comes  on  in  youth ;  it 
generally  begins  by  an  exaggerated  and  morbid  self-feeling 
or  by  a  shallow  conceited  introspection,  or  by  a  frothy  and 
emotional  religious  condition,  or  by  a  restless  and  unsettled 
state,  with  foohsh  hatchings  of  philanthropic  schemes.  There 
is  no  continuity  or  force  in  any  train  of  thought  or  course  of 
action.  Then  comes  a  melanchoHc  stage  of  solitary  habits, 
disinclination  for  company,  especially  that  of  the  other  sex, 
irritability,  variableness  of  mood,  hypochondriacal  brooding, 
vacillation  and  perversion  of  feeling  towards  near  relations. 


534  THE   INSANITY   OF   MASTURBATION. 

Suicide  is  often  thought  of,  and  oftener  talked  of,  but  mas- 
turbation makes  most  of  its  victims  too  cowardly  to  kill 
themselves.  Then  an  acute  attack  follows,  usually  of  a 
maniacal  kind.  This  may  end  in  recovery,  or  may  run 
quickly  into  a  dementia  that  is  masturbational  in  character, 
being  solitary,  unsocial,  and  subject  to  impulses,  sometimes 
homicidal, — a  sort  of  masturbational  hyperkinesia. 

With  these  mental  symptoms  there  are  usually  well-marked 
bodily  signs  of  the  disease.  The  patient  is  thin,  pale,  and 
pasty,  with  a  cold  clammy  skin,  a  haggard  face,  and  an  eye 
that  never  looks  straight  at  you.  He  has  weakness  in  the 
back,  pains  in  the  head,  palpitation  of  the  heart,  impaired 
sight,  muscular  relaxation,  and  sometimes  spermatorrhoea. 
But  for  a  complete  record  of  the  feelings  and  symptoms  of  the 
youthful  masturbator  one  should  rather  go  to  those  shameful 
quack  advertisements  put  into  the  country  newspapers  than 
to  medical  books.  They  are  there  set  forth  at  large,  with 
just  enough  concealment  to  make  them  suggestive.  That 
such  abominable  suggestions  of  evil  should  be  allowed  to  be 
scattered  broadcast  into  the  families  of  decent  people,  is  to 
me  one  of  the  standing  marvels  of  our  social  life.  They  do 
and  can  do  no  good  to  any  one ;  they  aggravate  the  miseries 
of  those  who  are  suffering  from  the  minor  effects  of  this  vice 
by  keeping  them  constantly  before  their  minds ;  they  suggest 
evil  thoughts  to  those  who  might  be  free  from  them,  and  they 
fatten  the  vilest  of  mankind.  I  verily  believe,  and  I  speak 
from  some  experience,  that  there  are  about  as  many  people 
made  insane  by  these  advertisements  and  the  pamphlets 
sent  out  by  the  advertisers,  as  by  the  habit  of  masturbation 
itself. 

No  greater  condemnation  of  the  habit  of  masturbation  can 
be  imagined  than  the  changed  feelings  towards  the  other  sex 
wliich  it  produces.  Nature  there  as  elsewhere  punishes  the 
breaker  of  her  laws.  Such  perversions  of  feehng  are  very 
interesting  to  the  medico-psychologist.  Instead  of  the  true, 
healthy  pleasure,  intense  as  it  is  natural,  of  social  and  family 


THE  INSANITY   OF   MASTURBATION.  535 

intercourse,  there  conies  a  self-conscious  bashfulness,  a  painful 
conflict  between  desire  and  repugnance,  a  suspicious  constraint, 
and  'a'  guilty  avoidance.  The  evil  to  him  who  evil  thinks  is 
seldom  more  marked  than  in  the  case  of  the  masturbator. 
Any  method  through  which  this  habit  could  be  lessened 
among  our  rising  generation  would  certainly  do  great  good ; 
life  would  be  elevated  in  a  large  degree,  self-respect  would 
be  increased,  social  intercourse  would  be  sweetened  and  its 
pleasures  intensified ;  while  the  stings  of  self-accusation  and 
remorse  would  be  far  fewer  in  after-life. 

The  ordinary  type  of  masturhational  insanity  is  illustrated 
in  many  of  its  chief  features  in  this  case. 

J.  W.,  set.  22,  a  young  man  of  a  naturally  cheerful  and 
frank  disposition  and  steady  habits,  and  with  a  good  family 
history  so  far  as  known.  When  an  infant  he  was  delicate, 
and  was  supposed  to  have  been  threatened  with  hydroce- 
phalus, and  he  had  convulsions  during  his  first  dentition. 
Those  symptoms  no  doubt  implied  a  neurotic  heredity.  Since 
then  his  health  had  been  good  up  to  his  present  malady.  For 
years  after  puberty  he  indulged  in  the  habit  of  masturbation 
to  a  great  excess.  He  gradually  fell  off  in  looks  and  bodily 
vigour,  and  mentally  he  became  changed.  He  got  egotistical, 
hypochondriacal,  changeable  in  his  resolutions,  fanciful  and 
unsocial.  Those  symptoms  did  not  come  on  all  at  once,  but 
took  years  fully  to  develop.  They  seemed  to  follow  a  diminu- 
tion of  nervous  tone  and  general  bodily  strength.  At  last 
the  mental  depression  stood  out  from  all  the  other  mental 
symptoms.  It  was  hypochondriacal  in  character.  He  thought 
his  sexual  organs  were  "  all  gone,"  that  his  chest  was  "  falling 
in  " ;  he  complained  of  pains  in  his  back  and  in  his  head, 
and  that  his  back  was  "very  weak."  When  he  was  about 
twenty-two  he  made  several  feeble  ineffectual  attempts  to 
commit  suicide,  both  by  hanging  and  strangulation.  He  was 
then  sent  to  the  Asylum.  He  was  pale,  his  muscles  flabby, 
his  skin  moist  and  clammy,  his  tongue  coated,  his  bowels 
costive,  and  his  expression  depressed  and  furtive.     He  never 


536  THE   INSANITY   OF   MASTURBATION. 

could  look  one  in  the  face.  Masturbators  seldom  can ;  but 
do  not  put  doAvn  every  insane  person  who  cannot  look  you 
in  the  face  as  necessarily  a  masturbator.  His  genital  organs 
were  loose  and  flabby,  and  his  testicles  tender.  He  says  he 
suffers  from  spermatorrhoea,  but  has  now  no  natural  sexual 
desire.  Yet  his  mind  runs  on  the  subject,  and  it  is  one  of  the 
great  sources  of  his  mental  depression  that  he  imagines  he  has 
lost  his  virility.  He  thought  himself  very  weak  indeed,  and 
that  he  could  not  get  better.  He  said  he  would  like  to  put  an 
end  to  liimseK,  and  yet  would  not  hke  to  do  so.  He  was 
ordered  compound  cod-liver  oil  emulsion  with  hypophosphites, 
strychnine,  much  milk  diet,  fresh  air,  cold  sponging,  and  a 
little  garden  work.  He  was  never  done  making  attempts  to 
strangle  himself  with  his  necktie.  In  about  three  months 
he  was  distinctly  improved.  His  whole  "tone"  was  better, 
of  mind,  general  nervous  action,  and  of  nutrition.  But  he 
could  scarcely  be  prevented  from  talking  about  himseM  and 
his  ailments,  imaginary  and  real.  He  wanted  medical  books 
to  read  about  his  case,  and  said  he  had  bought  and  read  all 
the  quack  literature  on  "nervous  depression,"  &c.,  he  could 
lay  his  hands  on,  which  always  made  him  worse.  He  ate 
and  slept  well,  and,  it  was  feared,  continued  his  evil  habit, 
but  not  to  any  great  extent.  In  six  months  he  had  gained 
in  weight,  could  employ  himself  more,  and  was  much  more 
cheerful.  He  was  sent  home  half -cured,  on  the  theory  that 
he  would  there  have  more  motives  to  rouse  himself  and  go 
to  work.  That  he  did,  and  after  a  year  he  was  pretty 
well. 

Here  is  the  extract  from  a  very  instructive  lettefr  to  me  from 
J.  X.,  a  lad  of  22,  a  masturhator,  who  for  tioo  years  had  been 
hypochondriacal  and  unsettled,  and  alternately  elevated  and 
depressed  in  mind : — "If  I  had  come  hke  a  man  to  the  point, 
and  told  the  doctors  what  was  the  real  matter  with  me — 
but  in  fact  I  really  did  not  know  myself  till  some  time  ago. 
I  have  committed  masturbation  for  some  years  back,  and 
sometimes  as  often  as  three  times  a  day.     I  am  sure  I  cannot 


THE   INSANITY   OF   MASTURBATION.  537 

explain  myself  nor  give  account  of  sucli  conduct.  Sometimes 
I  felt  so  uneasy  at  my  work  that  I  would  go  to  the  W.C.  to 
do  ity  and  it  seemed  to  give  me  ease,  and  then  I  would  work 
like  a  hatter  for  a  whole  week  till  the  sensation  overpowered 
me  again.  I  have  been  the  most  filthy  scoundrel  in  existence. 
I  did  not  know  at  that  time  what  harm  I  was  doing  myself, 
although  I  knew  I  was  doing  something  filthy  and  wrong, 
and  many  are  the  times  I  have  made  resolutions  to  put  a  stop 
to  such  conduct,  and  sometimes  managed  for  a  month,  not 
more.  Owing  to  my  trade  I  fell  in  with  lots  of  girls,  but 
never  cared  much  about  speaking  to  them,  owing,  I  beheve, 
to  me  doing  that  filthy  practice."  He  describes  how  he  tried 
to  have  connection  with  a  girl  with  whom  he  thought  he  had 
at  last  fallen  in  love,  and  that  he  failed,  and  that  he  was  dis- 
gusted with  himself  and  her.  "  This  and  other  things,  with 
my  business  not  getting  on,  I  was  most  determined  to  end  my 
miserable  career."  He  then  described  how  he  took  laudanum, 
and  how  he  felt  afterwards.  "I  hope  for  my  father's  sake 
you  will  give  me  your  advice,  not  for  my  sake,  for  I  am  not 
worth  taking  notice  of.  Some  time  ago,  when  I  was  wonder- 
ing if  there  was  any  seed  left  in  me  at  all,  I  committed  mas- 
turbation, but  had  to  do  it  for  a  considerable  time,  and  after 
some  did  come  it  was  dull  in  the  colour  and  scanty,  and  instead 
of  a  pleasant  sensation  it  pained  me."  After  a  month  or 
two  this  lad's  depression  passed  ofl^,  and  as  his  bodily  health 
improved  he  became  excitable,  restless,  egotistical,  and  irri- 
table. This  lasted  for  a  time,  and  he  then  appeared  to  get 
quite  well  in  mind  and  body. 

Early  Masturbation. — I  have  known  many  instances  of  the 
habit  of  masturbation  being  taken  to  without  any  teaching, 
and  in  some  cases  at  incredibly  early  ages.  I  have  now  a 
patient,  J.  Y.,  who  was  always  nervous,  diffident,  unable  to 
earn  his  own  livelihood,  tending  to  be  depressed  and  suicidal 
at  times,  and  egotistically  irritable,  conceited,  and  impracti- 
cable. At  other  times,  every  now  and  then,  he  got  so  de- 
pressed that  he  had  to  be  sent  into  the  Asylum,  or  came  into 


538  THE   INSAlSHTY  OF   MASTURBATION. 

it  of  his  OAvn  accord.  This  man  has  frequently  assured  me, 
when  at  liis  best  mentally,  that  he  acquired  the  habit  "svhen 
he  was  six  years  of  age,  that  no  one  taught  him,  that  almost 
ever  since  it  has  been  his  bane  and  curse,  that  he  knew  as 
well  as  any  one  how  wrong  it  was  to  practise  it,  and  that  it 
did  liim  infinite  harm  in  body  and  mind ;  and  he  said  that  at 
times  his  mind  was  filled  with  disgust  at  the  filthy  nature  of 
the  practice,  and  despair  at  the  hold  it  had  acquired  over  him. 
Yet,  in  spite  of  all  this,  he  could  not  stop  it,  the  morbid 
fascination  over  his  mind  was  so  powerful.  He  described  it 
as  hke  a  fate  that  he  must  yield  to,  an  involuntary  act  over 
which  his  will  seemed  to  have  no  control,  though  the  practice 
of  it  was  at  times  painful  and  not  pleasurable.  Yet  I  have 
seen  few  cases  in  which  suitable  treatment,  control,  fresh  air, 
hard  work  in  the  garden,  and  suitable  food  had  so  good  an 
effect  at  first.  After  two  or  three  months  he  became  another 
man,  lost  to  a  great  extent  his  hang-dog  look,  his  depression,  his 
suspicions,  and  his  hypochondriacal  notions,  got  fresher  and 
fatter,  and  had  less  marked  inchnation  towards  his  evil  habit. 
But  it  unmanned  him,  and  made  him  quite  unfit  for  facing  the 
world.  So  anxious  was  he  to  be  cured,  that  he  had  himself 
castrated.  This  has  stopped  the  tendency  to  masturbation, 
but  mentally  some  depression  and  "nervousness"  remain. 
He  married  after  a  time,  and  says  he  derived  a  sort  of  modified 
pleasure  from  sexual  intercourse.  But  the  depression  became 
tinctured  with  suspicions,  and  then  he  got  irritable,  excited, 
and  took  to  hquor  when  he  could  get  it.  He  imagined  his 
vnie  was  unfaithful  to  him,  and  that  his  relatives  were  con- 
spiring against  him.  With  all  that  he  became  enormously 
fat.  He  had  to  be  sent  back  to  the  Asylum,  the  castration 
having  proved  a  failure,  and  his  mental  power  now  being 
enfeebled.  He  is,  in  fact,  demented.  I  lately  saw,  in  con- 
sultation with  Dr  Eonaldson,  a  girl  of  six  who  had  become 
addicted  to  the  habit,  who  did  not  know  its  nature,  and  who 
looked  a  sweet,  innocent  httle  creature.  She  was  getting 
pale  and  nervous,  apparently  under  its  evil  influence.     There 


THE   INSANITY   OF   MASTURBATION.  539 

seemed  to  be  some  irritation  at  tlie  orifice  of  the  vulva,  whicli 
had  set  up  the  habit.  Local  cleanliness  and  mild  antiseptic 
lotions,  -the  use  of  small  doses  of  the  bromide  of  soda,  open- 
air  exercise,  amusements,  and  constant  watching,  with  a  pad 
between  the  knees  at  night,  and  a  mild  restraint  of  the  hands 
to  begin  with,  were  adopted.  She  indulged  in  the  habit 
chiefly  when  going  asleep  and  when  waking  out  of  sleep.  It 
seemed  to  give  no  pleasure  that  could  be  called  sexual. 

There  is  no  doubt  that  the  act  of  masturbation  is  often  not 
only  done  involuntarily  and  contrary  to  every  inclination  of 
the  will,  especially  just  after  awaking  from  sleep,  but  it  may 
also  be  unconsciously  done.  I  have  seen  it  done  in  the  un- 
conscious period  immediately  after  an  epileptic  fit ;  and  in 
the  unconscious  stages  of  acute  mania  and  excited  melancholia 
it  is  very  common. 

Many  of  the  cases  do  not  recover.  I  have  many  patients 
in  the  Asylum,  of  whom  this  is  a  type  : — K.  A.,  set.  37. 
Began  to  masturbate  at  15,  and  has  continued  the  practice 
to  excess  ever  since.  He  became  so  insane  as  to  require  to 
be  sent  to  the  Asylum  at  20,  after  a  year  or  two  of  restless 
egotism  and  selfish  hypochondriasis,  varied  by  spurts  of 
equally  selfish  emotional  religionism  at  home.  He  at  first 
could  reason,  read,  and  occupy  himself  a  little,  but  as  the 
habit  has  gone  on  his  mental  power  has  gradually  weakened, 
his  social  instincts  have  become  extinguished,  his  self-respect 
and  all  his  sense  of  decency  have  become  utterly  lost.  He  is 
now  a  slouching,  untidy -looking  fellow,  with  a  hang-dog  look, 
who  can  never  be  got  to  look  you  in  the  face,  who  never  reads 
or  speaks  to  any  one,  cares  nothing  for  his  relatives,  has  no 
energy,  looks  pale,  red-nosed,  and  pinched.  And  yet  he  is 
not  quite  demented  in  the  ordinary  sense.  He  is  coherent, 
and  you  find  his  memory  is  not  gone  when  you  talk  to  him. 

Treatment. — The  general  principles  of  treatment  of  mastur- 
bational  insanity  unquestionably  are  to  brace  up  the  youth 
bodily,  mentally,  and  morally.  In  the  first  place  the  diet 
should  be  unstimulating  and  fattening.     It  is  strange  that  the 


540  THE   INSANITY   OF   MASTURBATION. 

physiological  inductions  of  the  old  CathoHc  Church  as  to  the 
dietetic  management  of  the  nisus  generativzis  and  its  voKtional 
control  have  heen  so  neglected  by  modern  physicians,  founded 
as  they  were  on  the  experiences  of  the  terrific  conflict  with 
nature  that  was  imphed  in  the  early  Christian  theory  that 
sexual  desire  was  more  or  less  of   the  devil  and  should  be 
eradicated  and  not  merely  regulated  by  all  men  who  wished 
to  attain  a  high  religious  ideal,  and  on  the  experiences  of  the 
later  rule  of  priestly  celibacy.     My  own  belief   is  that  the 
CathoKc  view  of  repression  and  eradication  being,  for  the  sake 
of  argument,  granted,  almost  every  rule  of  the  Church  as  to 
food  and  fasting,  and  every  practice  of  the  monastic  orders, 
and  every  conventual  regulation,  is   a  correct   physiological 
principle.      Translated     from     religious    into     physiological 
language,  they  may  be  summed  up   thus : — Strengthen  the 
power  of  inhibition,  bodily  and  mental.     Practise  the  habit  of 
mental  concentration  and  abstraction  from  certain  lines  of 
thought.     Cultivate  enthusiasm  about  ideals.     Find  ideal  out- 
lets for  the  affective  and  social  faculties  other  than  sexual 
choices.     Sleep  only  under  such  conditions  and  so  long  as  to 
recuperate   lost    energy  and   tissue,  and   not   to   accumulate 
energy  that  there  might  be  a  difficulty  in  getting  rid  of  short 
of   sexually.     Eat   only  non-stimulating  and  fattening  food, 
and  that  in  moderation,  with  periodic  abstentions  to  use  up 
spare  material  in  the  body.     Avoid  flesh,  as  the  incarnation 
of  rampant,  uncontrollable  force,  sexual  and  otherwise.     Be 
much  in  the  open  air,  and  work  hard.     Finally,  so  fill  up 
and  systematise  the  time  that  none  is  left  for  day-dreaming. — 
1^0 w,  such  are  undoubtedly  the  proper  rules  with  which  to 
treat  the  habit  of  masturbation  and  its  mental  and  bodily 
effects.     If  we  add  to  those  the  medical  means  of  cold  baths, 
tonics,   games,    family    life,    and    a    course    of    bromide    of 
potassium,    our   resources   are    pretty   nearly   exhausted,     I 
would  certainly  avoid  local  treatment  or  mechanical  appli- 
ances as  a  general  rule.     It  is  no  doubt  possible  to  make  the 
organs  of  generation  so  sore  that  excitation  of  them  becomes 


THE   INSANITY   OF   MASTURBATION.  541 

impossible ;  and  if  the  patient's  imagination  lias  disappeared 
through  his  dementia,  this  rest  from  constant  nervous  ex- 
haustion may  be  taken  advantage  of  to  feed  him  up  and  get 
him  into  habits  of  working,  and  into  a  comfortable  dementia. 
That  is  a  good  thing,  but  it  only  applies,  in  my  experience,  to 
those  whose  mental  power  is  already  gone.  For  the  mastur- 
bator  whose  mental  energy  still  exists  to  some  extent,  or  is 
only  temporarily  suspended,  such  mechanical  expedients  and 
obviators  of  present  indulgence  only  concentrate  the  attention 
on  the  function,  and  cause  desires  that  are  intense  in  propor- 
tion to  the  present  impossibility  of  gratifying  them.  Do  not 
recommend  marriage  as  a  remedy.  It  is  a  most  dangerous 
experiment.  It  is  apt  to  be  followed  by  sexual  repugnance 
in  a  short  time,  and  the  last  state  is  worse  than  the  first,  two 
persons'  happiness  being  destroyed  instead  of  one. 

There  have  been  forty-six  cases  that  I  have  diagnosed  as 
masturbational  insanity  sent  to  the  Royal  Edinburgh  Asylum 
during  the  past  nine  years,  and  of  these  sixteen,  or  35  per 
cent.,  have  made  good  recoveries,  doing  their  work  in  hfe 
well  afterwards.  Some  of  the  cases  I  have  been  consulted 
about  out  of  the  Asylum,  and  some  of  those  I  have  had  under 
my  care  in  it,  are  now  occupying  responsible  positions  and 
doing  first-rate  work  in  the  world.  Some  are  the  fathers  of 
families.  There  is  no  ground  whatever  for  such  an  unfavour- 
able prognosis  in  any  case  as  I  have  known  some  medical 
men  give,  and  there  is  no  sort  of  ground  for  thinking  there 
is  any  special  risk  of  relapse,  or  any  special  form  of  nervous- 
ness, that  will  after  recovery  necessarily  stick  to  a  masturbator 
all  his  life.  Eighteen  more  of  the  cases  left  the  Asylum  more 
or  less  improved,  while  twelve  still  remain  there  hopeless, 
incurable,  and  degraded. 

Warning. — One  warning  I  have  to  give  before  I  have  done 
with  this  disagreeable  subject.  It  is  this  :  not  to  beheve  all 
the  melanchoHc  patients  who  attribute  their  bad  symptoms  to 
the  former  practice  of  this  vice  in  youth.  This  is  a  common 
self-accusation.     In  most  instances  it  is  a  mere  delusion,  like 


542  THE    INSANITY   OF   MASTURBATION. 

SO  many  other  melancliolic  delusions,  founded  on  a  morbid 
exaggeration  of  the  consequences  of  departure  from  strict 
rectitude.  It  just  amounts  to  the  same  tiling  psychologically 
as  that  the  loss  of  control  over  the  temper  and  calhng  a  friend 
a  bad  name  ten  years  ago  is  an  unpardonable  sin,  that  not 
going  to  church  on  a  certain  Sunday  will  be  punished  by 
eternal  damnation,  or  that  a  gonorrhoea  in  youth  has  so 
poUuted  the  blood  that  all  the  offspring  are  diseased,  and  that 
death  must  ensue.  The  real  significance  of  masturbation  in 
each  case  must  be  carefully  inquired  into,  and  the  facts  ascer- 
tained before  a  conclusion  as  to  its  effects  is  formed. 


LECTUEE   XV. 

PUERPEEAL  IN"SAI^ITY.  LACTATIONAL  INSAMTY. 
THE  lis^SANITY  OF  PEEGN"A:N"CY. 

Childbirth,  nursing,  and  pregnancy  in  women  are  liable  to 
act  as  the  exciting  causes  of  attacks  of  mental  disease.  In 
importance  and  frequency  they  stand  in  the  order  in  which  I 
have  placed  them.  For  many  reasons  it  is  especially  necessary 
that  the  general  practitioner  of  medicine  should  be  well 
acquainted  with  those  forms  of  insanity,  for  they  all  occur 
at  a  time  when  he  is  apt  to  be  attending  the  patient  for 
other  reasons,  they  can,  under  favourable  circumstances,  be 
treated  at  home  in  many  individual  cases,  and  it  is  well  so  to 
treat  them  when  possible.  They  are  all  very  curable  forms  of 
mental  disease,  and,  when  cured,  they  are  not  apt  to  leave  any 
traces  of  mental  weakness  or  obliquity  behind.  The  patients 
can  resume  their  work  and  place  in  the  family  and  society, 
and  be  as  if  they  had  never  been  ill.  The  three  forms  differ 
in  so  many  respects  that  I  must  take  them  separately. 

The  advantage  and  the  practical  necessity  of  classifying 
mental  diseases  in  other  ways  than  according  to  the  mental 
symptoms  present,  are  especially  seen  in  these  three  forms  of 
mental  disease.  To  know  that  a  case  is  one  that  has  begun 
after  recent  childbirth  is  to  know  far  more  about  it  than  to 
know  it  as  mania  or  melancholia  for  treatment  and  for 
prognosis.     There  is  no  practical  physician  but  will  admit  this. 


544  PUEEPEKAL  INSANITY. 


PUEEPERAL  II^SANITY. 

Limited  to  that  occuiTing  six  weeks  after  childbirth  ;  importance  of  this 
form  ;  forms  5  per  cent,  of  the  insanity  among  women  ;  occurs  in  1 
in  400  labours  ;  one-half  of  the  cases  occur  in  first  week  after 
delivery  ;  four-fifths  within  the  second  week  ;  most  frequent  in 
primipartE  ;  in  one-third  of  the  cases  diSicult  or  complicated  labour  ; 
risk  diminishes  with  each  successive  labour  ;  hereditary  predisposi- 
tion in  about  half  the  cases  ;  72  per  cent,  of  all  the  cases  very  acute 
in  character  ;  the  acutest  form  of  clinical  insanity — maniacal  and 
melancholic  forms  ;  57  out  of  73  cases  maniacal  ;  suicidal  impulse 
in  one-third  of  the  cases — Synyytorns :  Change  of  manner  ;  inatten- 
tion ;  carelessness  about  child  ;  danger  to  child's  life  ;  incoherence  ; 
mania  ;  eroticism  ;  feeble  pulse  ;  clammy  skin  ;  weak  bodily  state  ; 
stoppage  of  lochia  ;  septic  condition  of  womb  ;  high  temperature, 
and  its  significance  ;  recovery  after  T.  of  over  105°  ;  tenderness 
over  womb — Prognosis :  Good  ;  75  per  cent,  recover  completely  ; 
8  per  cent,  die — Treatment :  Good  nursing ;  feeding  often ; 
stimulants  in  large  quantities ;  sedatives ;  asylum  treatment 
depends  on  circumstances  of  patient ;  counter-irritation  over  uterus  ; 
antiseptic  washes  ;  large  doses  of  quinine. 

I  do  not  know  any  event  than  can  occur  in  a  family,  short 
of  death,  that  is  so  great  a  shock  to  all  who  have  to  do  with 
it  as  for  a  new-made  mother  of  a  first-born  child  to  become 
suddenly  maniacal,  and  require  to  be  sent  to  an  asylum. 
One  of  the  most  joyous  times  of  Hfe  is  made  full  of  fearful 
anxiety,  and  the  strongest  affection  on  earth  is  then  often 
suddenly  converted  by  disease  into  an  antipathy :  for  the 
mother  not  only  "forgets  her  sucking  child,"  but  often 
becomes  dangerous  to  its  life.  And  few  things  are  more 
pleasant  than  to  see  the  restoration  of  the  mother  back  to  all 
that  makes  her  life  worth  having. 

Frequency,  Time,  Cause. — Puerperal  insanity  is  technically 
limited  to  the  mental  disease  that  occurs  within  the  first  six 
weeks  after  confinement.  By  far  the  majority  of  the  cases, 
and  by  far  the  most  acute  and  characteristic  cases,  occur  within 
the  fijst  fortnight.  It  is  a  very  common  form  of  mental 
disease,  for  5  per  cent,  of  all  the  cases  of  iasanity  among 


PUERPERAL  INSANITY.  545 

"Women  are  puerperal,  and  I  think  it  is  a  low  estimate  that 
one  in  every  400  labours  is  followed  by  it.  In  one-half  of 
the  pajtients  the  disease  begins  within  the  first  week  after  con- 
finement, and  in  four-fifths  of  them  within  the  first  fort- 
night. In  regard  to  the  cause  of  the  disease,  therefore,  it  is 
definite  and  clear.  The  accompaniments  of  childbirth  produce 
it.  The  great  physiological  cataclysm  itself,  the  pains  of 
labour,  the  mental  excitement  and  stress,  the  maternal  emotion, 
the  exhaustion,  the  loss  of  blood,  the  open  blood-vessels  liable 
to  absorb  every  septic  particle,  the  sudden  diversion  of  the 
stream  of  vital  energy  from  the  womb  to  the  mammae,  the 
reflex  disturbances  on  an  unstable  brain  from  the  reproductive 
organs,  these  together  or  separately  are  the  causes  that,  acting 
on  an  unstable  brain  hereditarily,  set  up  one  of  the  most 
violent  mental  storms  that  the  physician  has  ever  to  treat. 
Symptoms. — It  comes  on  very  suddenly  in  most  cases.  The 
mother  looks  self-absorbed  and  dull.  She  does  not  take  such 
notice  of  the  baby  as  is  usual,  or  much  interest  in  what  is 
going  on.  She  does  not  answer  questions  readily.  She  does 
not  eat,  and  she  does  not  sleep  at  night.  Next  morning  she 
is  restless.  Her  eyes  are  brilliant.  She  seems  to  have  no 
sense  of  exhaustion.  She  expresses  foolish  fancies,  such  as 
that  she  is  poisoned,  that  there  is  some  one  under  the  bed. 
She  takes  a  violent  dishke  to  the  doctor,  or  the  nurse,  or  the 
child.  She  begins  to  chatter  all  the  time,  and  her  talk  becomes 
less  and  less  connected.  She  is  erotic,  joyous,  scolding,  and 
perfectly  incoherent,  all  within  a  few  hours.  She  gets  violent, 
and  needs  to  be  held  in  bed ;  impulsively  and  without  set 
intent  she  attempts  suicide,  or  tries  to  kill  her  baby,  or  to 
tlirow  herself  out  of  the  window.  She  seems  as  if  she  had  a 
supernatural  strength.  Yet  when  you  feel  her  pulse  it  is  weak 
and  thready,  her  face  looks  haggard,  her  temperature  has  risen 
to  100°  or  more,  her  womb  is  tender  on  pressure  over  the 
abdomen,  and  she  will  not  look  at  food.  Her  lochia  have  first 
become  somewhat  offensive  and  then  stopped.  Her  skin  is 
moist  and  clammy.  She  soon  ceases  to  know  those  about  her, 
•     "       '  2  m 


546  PUERPERAL  INSANITY. 

calls  her  friends  by  other  names,  and  strangers  by  tlie  names 
of  her  friends.  Her  lips  and  tongue  show  signs  of  getting  dry. 
If  she  is  poor  or  cannot  get  plenty  of  nursing  or  medical 
attendance,  she  must  be  sent  to  the  nearest  asylum,  and  the 
sooner  the  better,  for  she  needs  all  that  the  asylum  can  do  for 
her.  She  needs  to  be  fed  at  once,  nolens  volens — by  means  of 
the  rubber  nose-tube  if  she  will  not  take  it  otherwise — with 
plenty  of  milk  and  eggs,  and  soups,  and  wine,  and  this  needs 
to  be  repeated  every  few  hours.  Let  her  alone  and  she  dies. 
!N"arcotise  her  with  morphia,  and  her  secretions  dry,  her  tongue 
gets  furred  and  hard,  and  her  antipathy  to  food  is  doubled. 
But  nurse  and  feed  her  Avell  by  night  and  day,  striking  the 
happy  mean  between  undue  restraint  and  too  great  activity, 
get  her  out  for  a  httle  in  the  open  air  after  some  days,  keep 
up  the  attendance,  and  in  a  week  she  will  show  a  little  sign 
of  mental  coherence,  in  a  fortnight  her  appetite  will  have 
returned,  her  pulse  will  be  stronger,  her  temperature  will  have 
fallen  to  normal,  and  she  will  walk  out  comfortably  without 
tearing  her  clothes  or  throwing  herself  about.  In  a  month 
she  will  be  knitting  a  stocking,  and  will  know  her  friends 
when  they  come  to  see  her.  Within  three  months  she  is  well 
— a  joyous  mother,  in  her  right  mind,  clasping  her  child,  the 
whole  of  the  disturbed  mental  period  seeming  like  a  dream 
'to  her,  that  is  very  soon  altogether  forgotten  in  her  new  duties 
and  dehghts. 

Although  puerperal  insanity  is  more  frequent  in  first  than 
in  subsequent  confinements,  yet  it  is  common  enough  in  the 
latter,  and  I  have  known  a  woman,  K.  B.,  who  had  six  attacks 
of  puerperal  insanity,  having  one  after  the  birth  of  each  cliild 
she  had,  and  she  recovered  from  them  all.  But  this  is  the 
exception.  The  woman  that  cannot  have  a  baby  without 
having  also  puerperal  insanity,  and  who  persists  in  having 
babies,  usually  remains  more  or  less  permanently  affected 
after  the  tliird  or  fourth  attack. 

Predisposing  Causes. — The  ordinary  causes  of  mental  disease 
contribute  as  predisposing  causes  towards  puerperal  insanity. 


PUERPERAL  INSANITY,  54? 

Poverty  and  want  of  proper  attendance  during  childbirth,  and 
having  to  get  out  of  bed  and  to  work  too  soon,  I  have  seen 
bring  it  on.  The  shame  and  mental  distress  usually  attending 
the  birth  of  illegitimate  children  make  it  twice  as  common 
then  as  after  the  birth  of  legitimate  children.  I  have  several 
times  seen  a  sudden  mental  shock  act  as  the  proximate  cause 
of  the  disease  in  women  who  seemed  to  be  doing  well  in  child- 
bed. I  once  saw  the  news  of  the  death  of  the  patient's  father 
send  a  woman,  in  the  second  week  after  confinement,  into 
acute  mania  within  a  few  hours.  But  such  moral  oa?  other 
causes  are  not  at  all  necessary  to  produce  the  disease,  over 
and  above  the  puerpei'al  condition.  In  by  far  the  majority 
of  the  cases  there  is  no  other  cause.  It  occurs  in  ladies  with 
every  comfort  and  attendance  as  well  as  among  the  poor. 

Mode  of  Recovery.  — Most  of  the  recoveries  from  puerperal 
insanity  are  gradual  ones.  We  do  not  commonly  find  those 
sudden  wakenings  up  from  an  acute  delirious  condition  into 
coherence,  self-control,  and  sanity  that  we  sometimes  see  in 
other  forms  of  mental  disease.  That  is,  in  my  opinion,  one  of 
the  reasons  why  the  recoveries  are  apt  to  be  complete  and  per- 
manent. I  do  not  hke  very  sudden  recoveries  in  any  form  of 
mental  disease,  because  they  are  not  so  apt  to  be  permanent,  and 
they  indicate  an  essentially  unstable  dynamical  condition  of  the 
convolutions,  I  am  never  quite  satisfied  about  the  recovery 
of  a  puerperal  case  until  the  woman  gets  stout  and  strong, 
and  until  her  menstruation  has  returned  and  becom.e  regular. 

The  following  is  a  typical  case  of  puerpeml  insanity  of  the 
acute  hut  not  deliriotis  hind: — K.  C,  set.  19,  a  hard-working 
domestic  servant,  with  no  known  heredity  to  the  neuroses. 
Though  she  came  of  a  "  respectable "  family,  she  had  an 
illegitimate  child  born  in  the  Maternity  Hospital,  Her 
labour  was  not  specially  severe,  and  she  did  well  for  three 
days.  Then,  without  any  new  cause,  she  got  dull  and  took 
no  notice  of  her  child  or  of  anything  else ;  in  a  few  hours  she 
began  to  laugh  hysterically,  then  she  got  more  excited,  rest- 
less, noisy,  and  talked  incoherently  about  religious  matters. 


548  PUERPERAL   INSANITY. 

She  did  not  sleep,  and  in  four  days  she  had  to  be  sent  to  the 
Asylum.  On  admission  she  was  much  excited  and  greatly 
exalted  in  mind.  She  mistook  the  identity  of  every  one  near 
her.  She  sung  on  at  the  pitch  of  her  voice  in  a  rhyming  way, 
putting  her  delusions  and  conversation  with  herself  into  rhyme. 
Her  ideas  and  currents  of  thought  were  always  changing.  She 
looked  pale.  Her  pulse  was  weak,  and  her  temperature  was 
98*2°.  She  did  not  sleep  for  the  first  week  at  all.  She  was 
restless,  singing,  loquacious,  and  delusional  all  that  time.  She 
was  put  on  all  sorts  of  very  nourishing  food,  especially  custards 
or  milk  and  eggs,  and  she  was  taken  out  into  the  open  air  for 
a  short  time  each  day  after  the  first  two  days.  She  began  to 
sleej)  in  a  week,  and  after  that  slept  more  or  less  regularly. 
She  continued  restless,  good-natured,  and  talkative,  destructive 
to  her  clothes  at  times,  full  of  boisterous  half-incoherent  fun, 
and  unable  to  settle  to  do  any  work  for  two  months.  She 
gained  in  weight  all  that  time,  eating  well  and  spending  much 
time  in  the  open  air.  Then  she  began  to  work,  was  put  to 
rough  scrubbing  and  laundry  work,  so  getting  rid  of  her 
excessive  muscular  energy.  In  three  months  she  was  fatten- 
ing, becoming  quiet,  and  working  hard.  In  four  months 
after  admission  she  was  stout,  sensible,  and  well  in  mind  and 
body,  menstruation  having  begun,  and  she  was  then  sent  back 
to  her  situation,  wliich  had  been  kept  open  for  her  in  con- 
sideration of  her  previous  good  conduct. 

Some  of  the  very  acute  cases  with  a  high  temperature  and 
most  unfavourable  symptoms  maJce  good  recoveries,  if  proper 
treatment  is  adopted  soon  enough,  as  in  this  case  : — 

K.  D.,  set.  27.  A  married  woman  of  correct  habits,  with  no 
known  heredity  to  insanity  ;  her  first  child.  Her  labour  was 
natural.  Things  went  on  well  for  a  week,  then  without 
apparent  cause  she  began  to  complain  of  headache  and  costive- 
ness.  She  got  restless  and  sleepless,  then  next  day  she 
became  foolishly  talkative  and  erotic,  and  neglected  the  child. 
The  lochia  and  milk  stopped.  She  refused  food  absolutely, 
getting  Avorse  day  by  day,  and  becoming  weaker  fast.     She 


PUERPERAL  INSANITY.  549 

wanted  a  razor  to  cut  her  tliroat,  and  thiew  a  tumbler  at  her 
husband,  but  was  not  very  suicidal  nor  dangerous.  In  two  or 
three  'days  she  was  absolutely  delirious  and  incoherent,  but 
was  not  sent  to  the  Asylum  for  seven  days  after  the  mental 
symptoms  appeared.  On  admission  she  was  greatly  excited, 
shut  her  eyes  tightly,  singing  and  swearing  and  using  the 
most  obscene  language  continuously.  She  seemed  to  imagine 
she  was  in  hell  and  surrounded  by  devils  at  one  time,  and 
she  had  exalted  fancies  at  other  times.  She  did  not  sleep  at 
night,  and  with  the  utmost  difficulty  was  got  to  take  some 
little  liquid  nourishment.  Her  temperature  was  found  to  be 
100°.  Her  pulse  was  very  thready,  her  skin  clammy.  She 
was  constantly  jerking  and  throwing  her  limbs  about,  her 
tongue  tending  to  be  dry,  and  her  general  bodily  condition 
one  of  great  exhaustion.  She  got  10  grains  of  chloral  and 
slept  three  hours  the  first  night.  Next  day  she  was  fed  with 
the  nose-tube  with  a  custard  containing  three  eggs,  one  pint 
milk  and  cream,  some  strong  beef-tea,  4  oz.  port  wine,  and  5 
grains  quinine.  This  acted  as  a  soporific,  and  she  slept  well 
most  of  the  afternoon.  After  awaking  she  was  less  excited, 
but  confused  in  mind.  This  mode  of  feeding  was  continued 
twice  a  day.  On  the  fourth  evening  after  admission  her 
temperature  was  103"8°,  but  mentally  she  seemed  to  have  a 
lucid  interval,  being  rational,  and  she  then  took  her  food. 
Some  foetid  lochial  discharge  made  its  appearance  at  this  time. 
Weak  carbohc  vaginal  syringing  was  used.  On  the  sixth  day 
she  became  again  acutely  maniacal,  with  a  morning  tempera- 
ture of  101  "4°,  an  evening  temperature  of  102"8°,  and  she  had 
to  be  fed  with  the  tube.  On  the  eighth  day  was  sleepy  and 
quiet,  took  her  food,  and  after  two  days  of  confusion  of  mind 
got  quite  sane,  and  remained  so,  remembering  nothing  of 
what  had  taken  place  during  her  illness.  I  allowed  her 
friends  to  remove  her  on  the  twenty-first  day,  she  having  a 
good  home,  where  her  bodily  strength  could  be  got  up  as  well 
as  in  the  Asyhim,  and  she  has  kept  well  ever  since. 

No  Relapses. — Puerperal  insanity  is  that  form  of  mental 


550  PUERPERAL   INSANITY. 

disease  where  we  are  least  apt  to  have  relapses  after  the 
patients  have  once  fairly  become  convalescent ;  and  I  have 
less  hesitation  in  letting  relations  remove  them  from  the 
Asylum  at  an  early  period,  if  they  have  good  homes  and 
attendance,  than  in  any  other  form.  In  this  case  of  K.  D.  I 
looked  on  the  feeding  at  once  as  having  saved  her  hfe.  The 
immediate  sedative  and  soporific  effect  of  filling  the  stomach 
with  food  and  stimulants  was  most  striking,  and  I  very  often 
see  this.  There  is  no  doubt  whatever  in  my  mind  that 
alcohohc  stimulants  along  with  food  are  of  the  utmost  service 
in  many  cases  of  puerperal  insanity,  their  good  effects  being 
more  immediate  in  my  opinion  than  in  any  other  form  of 
mental  disease. 

Home  Treatment. — In  the  case  of  patients  being  attacked 
with  puerperal  insanity  who  have  good  homes,  especially  if 
they  are  in  the  outskirts  of  a  town  or  in  the  country,  and  can 
get  constant  medical  attendance  and  good  trained  nursing, 
they  may  be  often  treated  at  home.  I  lately  attended  a  lady 
in  consultation,  K.  E.,  who,  within  ten  days  after  confine- 
ment, became  sleepless  and  restless,  took  antipathies  to  her 
doctor,  montlily  nurse,  and  child,  mistook  the  identities  of 
all  those  about  her,  calling  me  by  the  name  of  an  old  friend, 
had  a  temperature  of  101°,  with  slight  uterine  tenderness 
and  absolute  refusal  of  food,  being  also  most  troublesome 
and  difficult  to  manage.  I  sent  a  first-rate  attendant  from 
the  Asylum  in  addition  to  the  ordinary  nurse  and  servants, 
and  she  was  fed,  controlled,  nursed,  taken  out,  and  got 
through  her  attack  in  about  six  weeks,  just  as  well  as  if  she 
had  been  sent  to  an  asylum.  But  the  strain  and  respon- 
sibility on  relations,  attendants,  and  nurses  were  no  doubt 
most  severe,  who  were  nearly  exhausted  by  the  time  the 
patient  had  recovered. 

The  folloiuing  case  had  a  melancholic  character  throughout, 
though  acute  and  c^trahle : — K.  F.,  aet.  23.  No  heredity 
ascertained.  Had  been  a  strong  healthy  young  woman,  and 
had  had  one  child  previously  eighteen  months  ago.      This 


PUERPERAL  INSANITY.  551 

child  took  a  convulsive  attack  within  a  week  after  her  second 
confinement,  and  the  fright  and  shock  of  this  seemed  at  once 
to  upset  her  mentally,  for  she  was  within  a  few  hours  after- 
wards incoherent  and  maniacal.  She  was  put  under  chloro- 
form, and  got  morphia  in  quantities,  and  was  kept  under 
the  chloroform  almost  continuously  for  a  week.  This 
deadening  of  the  brain  functions  did  not  cure  the  maniacal 
condition ;  whenever  she  awoke  she  was  as  bad  as  ever. 
But  next  week  she  was  almost  sensible.  After  that  the 
acutely  maniacal  condition  returned,  and  after  a  week  of  it 
she  was  sent  to  the  Asylum.  She  was  then  intensely  de- 
pressed, looking  afraid  of  something  going  to  happen  to  her, 
imagining  that  something  was  in  the  bed.  Her  memory  was 
gone.  She  did  not  know  her  husband,  and  mistook  the 
identity  of  the  people  about  her.  She  had  hallucinations  of 
hearing.  Her  pulse  was  120,  feeble  and  intermittent.  Her 
temperature  104*2°.  Altogether  she  was  very  exhausted. 
She  was  fed  hourly  with  custards  and  sherry  in  large 
quantity.  On  the  second  day  after  admission  her  tempera- 
ture suddenly  sank  to  97 '2°  and  her  pulse  to  78,  and  this 
was  coincident  with  the  appearance  of  a  profuse  bloody 
lochial  discharge.  Mentally  she  was  also  much  improved, 
though  not  quite  rational.  Towards  evening  she  became 
restless,  and  had  the  hallucinations  of  hearing  again,  though 
her  temperature  was  only  98°.  She  did  not  sleep,  and  was 
very  depressed  and  restless  next  day,  saying  she  was  a  great 
prodigal  and  a  sinner,  but  took  food  voluntarily,  though 
needing  forcing  to  take  enough.  The  temperature  never 
again  rose  above  100°.  She  frequently  showed  the  morbid 
brain-tendency  of  repeating  a  word  or  some  of  the  syllables 
of  it  said  in  her  hearing  over  and  over  again,  e.g.,  "Zachariah- 
iah-iah-iah — Zach-ire."  She  was  well  fed  and  nursed,  and 
usually  slept  about  three  or  four  hours  a  night.  In  a  week 
she  was  able  to  be  taken  out  into  the  garden,  and  slept  much 
better  after  this.  In  ten  days  had  small  abscesses  forming 
round  one  or  two  of  her  finger-nails.     This  "  critical  "  symp- 


552  PUERPERAL   INSANITY. 

torn — not  at  all  uncommon  in  cases  of  recent  mania  and 
melancholia  —  seemed  to  do  lier  general  brain  condition 
good.  She  passed  in  a  month  into  a  quiet,  lethargic,  rather 
suspicious  state,  and  somewhat  depressed,  hut  with  no 
intense  mental  pain,  and  no  delusions  expressed.  Then  she 
got  into  a  state  that  is  very  common  before  recovery  in 
patients  in  asylums, — one  of  discontent,  of  increasing  instant 
desire  to  "go  home,"  inability  to  understand  that  any- 
thing has  been  wrong,  or  that  further  treatment  away  from 
home  is  required.  I  have  ten  times  the  trouble  with  my 
patients — and  sometimes  with  their  relatives — in  this  stage, 
for  the  cliief  symptoms  of  the  disease  have  passed  off,  and 
the  patients  seem  rational.  She  was  dull  and  suspicious  in 
the  mornings,  and  quite  well  sometimes  in  the  evenings. 
All  tliis  time  she  was  gaining  in  flesh  and  colour  and  strength, 
walking  much,  drinking  much  mUk,  and  being  encouraged 
to  employ  herself  in  the  house.  In  three  months  she  was 
sent  to  our  seaside  house,  and  had  sea  air  and  sea  bathing, 
both  of  wliich  did  her  much  good.  By  that  time  she  had 
gained  a  stone  in  weight.  In  four  months  she  menstruated 
for  the  first  time,  the  last  cloud  of  depression  passed  away, 
and  she  was  sent  home  quite  well. 

The  following  is  a  typical  case  of  ipuerperal  insanity  dying 
of  septiccemia,  or  a  case,  more  probably,  of  puerperal  fever 
ivith  maniacal  symptoms  : — 

K.  G.,  aet.  23,  of  a  cheerful  disposition  and  good  habits. 
Sister  and  aunt  have  been  insane.  Has  been  married  between 
four  and  five  years,  and  has  had  four  children  in  that  time, 
all  born  dead,  all  the  labours  being  difiicult  on  account  of  a  de- 
formed pelvis.  Had  been  weak  during  all  the  last  pregnancy, 
and  had  pains  in  the  head  for  two  months  before  delivery. 
Premature  labour  was  induced  about  the  seventh  month,  with 
the  view  of  saving  the  child  and  making  her  labour  more  easy 
than  the  others  had  been.  In  a  day  or  two  after  deHvery  she 
began  to  see  faces  on  the  wall,  to  think  that  the  chairs  were 
alive,  and  that  people  Avere  whispering  slanders  about  her. 


PUERPERAL   INSANITY.  553 

She  did  not  sleep,  and  would  not  take  food.  She  got  rapidly- 
worse,  becoming  quite  maniacal,  delirious,  and  unmanageable. 
She '  imagined  poison  was  put  into  her  food,  and  wanted  to 
rush  away  from  home.  On  admission  she  exhibited  a  com- 
bination of  intense  excitement  in  paroxysms,  during  which 
she  required  three  attendants  to  hold  her  in  bed,  with  ex- 
treme prostration  and  weakness  between.  Her  pulse  was 
thready  and  156,  temperature  102°,  respirations  60.  There 
was  an  anxious  look,  with  great  pallor  of  countenance,  when 
not  excited.  There  was  evidence  of  congestion  of  both  lungs, 
with  pneumonia  at  the  bases.  There  was  no  evidence  of 
tenderness  on  pressure  over  uterus.  JSTo  lochial  discharge. 
She  was  fed  with  brandy  and  custards  on  admission,  and 
every  hour  thereafter,  getting  10  grains  of  quinine  every  two 
hours  for  the  first  eight  hours.  In  spite  of  all  that  could 
be  done  she  sank  on  the  sixth  day,  the  temperature  having 
kept  up  all  the  time  to  between  10r4°  and  103-8°,  the  lung 
symptoms  getting  worse,  and  the  intense  delirious  excitement 
coming  on  once  or  twice  every  day  except  the  last. 

On  post-mortem  examination  I  found  the  brain  intensely 
congested,  and  the  lungs  pleuritic,  very  congested,  and  almost 
hepatised  at  bases.  But  the  cliief  seat  of  disease  was  in  and 
round  the  womb.  There  was  a  thin  layer  of  pus  on  its  peri- 
toneal surface.  There  was  a  small  abscess  in  the  right  ovary, 
which  seemed  to  occupy  the  position  of  a  recent  corpus 
luteum.  The  uterus  was  large  and  flabby — about  6  inches  by 
3  inches — its  substance  on  section  containing  much  purulent 
matter  all  through  it,  but  especially  towards  the  mucous 
membrane  in  the  fundus.  The  mucous  membrane  was  thick- 
ened and  covered  with  yellowish  purulent  matter,  and  some 
of  the  remains  of  the  placenta  were  adherent.  One  of  the 
uterine  veins  on  the  right  side,  for  about  4  inches  in  its 
course  towards  the  vena  cava,  was  unusually  enlarged,  look- 
ing like  a  bit  of  very  small  intestine,  its  coat  thickened,  and 
its  lumen  filled  with  thick  grumous  pus. 
1    It  is  difficult  to  say  whether  this  was  a  case  of  "puer- 


554  PUERPEEAL  INSANITY. 

peral  insanity  "  with  septicaemia,  or  "  puerperal  fever  "  with 
maniacal  delirium.  I  think  the  latter  is  the  more  correct 
description.  It  was,  I  think,  evident  from  the  post-mortem 
appearances  that  there  was  septicaemic  puerperal  fever  from 
the  beginning,  and  this,  occurring  in  a  weakened  ansemic  brain 
predisposed  to  insanity,  no  doubt  produced  the  maniacal 
symptoms. 

Statistics.- — -I  have  gone  carefully  over  the  histories  of  all 
the  puerperal  cases  that  have  been  sent  here  during  the  past 
nine  years.  They  were  all  under  my  own  care,  and  the 
histories  were  taken  on  a  uniform  plan  of  my  own  by  the 
assistant-physicians.  There  were  seventy -five  cases  altogether 
counted  as  puerperal,  but  fifteen  of  these  were  either  old 
cases  not  sent  in  for  periods  over  a  year,  or  the  same  cases 
admitted  twice  during  the  same  attack.  These  I  omitted  as 
having  no  clinical  value.  The  remaining  sixty,  on  analysis 
and  study  of  their  characters  and  clinical  symptoms  and 
results,  form  a  very  instructive  physician's  lesson. 

Age. — Looking  at  their  ages,  it  seems  as  if  the  disease 
occurred  in  just  about  the  frequency  that  ordinary  confine- 
ments occur  at  the  same  ages.^  Forty-four  of  the  cases  had 
never  been  insane  before. 

Causation. — In  addition  to  the  puerperal  state  as  the  great 
exciting  cause  of  the  disease  in  those  sixty  cases,  I  found  that 
there  existed  as  a  predisposing  cause  a  heredity  to  insanity  in 
twenty-two  of  the  forty-nine  cases  in  which  this  point  could 
be  ascertained,  or  37  per  cent,  of  the  whole.  JSTo  doubt 
heredity  played  a  much  more  important  part  than  this  if  the 
facts  could  have  been  accurately  ascertained,  but  this  is  above 
the  average  of  the  ascertained  heredity  in  our  Asylum  tables 
for  the  same  nine  years.  Moral  causes  acting  during  the 
puerperal  state  were  common,  such  as  the  deaths  of  children, 

^  From  15  to  20  years  of  age  in    3  cases, 
„      20  „  25     „         „  16      „ 

„      25  „  30     „         „  20      „ 

„      30  „  35     „         „  9      „ 

„      35  „  40     „         ,,  12      „ 


PUERPERAL   INSANITY.  555 

desertion  of  husband,  frights,  &c.  The  incidence  and  import- 
ance of  such  causes  of  the  disease  are  best  shown  by  the  fact 
tliat  in  thirteen,  or  25  per  cent.,  of  the  cases  the  children  had 
been  illegitimate.  The  average  rate  of  illegitimacy  in  Edin- 
burgh is  about  one-third  of  this.  Severe  post-partum  haemor- 
rhage, or  difficult  or  instrumental  labours,  had  occurred  in  at 
least  ten  cases.  But  all  these  causes  leave  a  considerable 
proportion  of  the  cases  where  there  was  no  apparent  exciting 
cause  but  normal  labour  and  its  accompaniments. 

Number  of  Confinements. — Looking  next  at  the  question 
of  which  confinement  the  disease  most  frequently  followed,  I 
find  that  twenty  cases,  or  one-third  of  the  whole,  occurred 
after  first  confinements.  This  is  of  course  out  of  all  propor- 
tion to  the  number  of  first  confinements  in  the  population. 
The  remaining  two-thirds  happened,  some  in  each  confinement 
up  to  the  eighth.  This  merely  confirms  what  was  well  known 
before,  that  primiparce  are  most  subject  to  the  disease. 

Time  after  Confinement. — Then  as  to  the  period  of  occur- 
rence after  confinement.  In  eighteen  cases  this  was  not  pre- 
cisely ascertained,  but  in  nearly  all  these  it  was  within  the 
first  fortnight.  Of  the  remaining  forty -two  cases  the  disease 
began  within  the  first  week  in  twenty-one,  and  in  eleven 
more  within  the  second  week,  so  that  we  may  say  that  in  80 
per  cent,  of  the  cases  it  began  within  the  first  fortnight.  If 
that  period  is  passed  it  is  clear  that  the  chief  risk  is  over  in 
a  woman  in  childbed,  the  first  week  being  by  far  the  most 
liable  to  its  invasion.  At  least  half  the  cases  occur  then. 
Only  one  case  of  the  sixty  occurred  after  the  twenty-eighth 
day. 

Character  very  Acute. — The  next  point  is  very  important 
clinically.  Of  the  sixty  cases  no  less  than  forty-three  were 
very  acute  in  character  and  symptoms,  while  seventeen  only 
were  mild  and  without  acute  symptoms.  Twenty-nine  of  the 
forty-three  acute  cases  were  generally  maniacal  in  character, 
and  fourteen  generally  melancholic  with  motor  excitement, 
some  of  each  of  these  classes  changing  from  one  state  to  the 


556  PUEKPEKAL  INSANITY. 

other  at  times.  In  the  mild  cases  the  prevaiHiig  character 
was  mental  depression,  fourteen  of  the  seventeen  being  so. 
In  at  least  eighteen  of  the  acutely  maniacal  cases,  the  mania 
amounted  to  absolute  delirium,  with  no  power  of  attention 
and  no  coherence  of  speech  whatever.  I  know  of  no  cHnical 
form  of  insanity  that  would  yield  so  large  a  proportion  of  very 
acute  cases.  Puerperal  insanity  may  therefore  be  regarded 
as  the  most  acute  of  all  forms. 

Temperature. — The  temperature  of  all  cases  on  and  after 
admission  was  taken.^  It  is  very  instructive  to  look  at  the 
column  of  highest  temperatures  in  each  case. 

Of  the  sixty  there  were  thirty -four  cases  under  99°,  and 
therefore  they  cannot  be  said  to  be  much  above  the  average 
temperature  of  ordinary  health,  or  at  all  events  of  the  average 
temperature  of  the  insane.  But  twenty-six  cases,  or  43  per 
cent,  of  the  whole,  were  over  this,  and  of  these  fourteen  cases, 
or  23  per  cent,  of  the  whole,  were  over  100°.  jN"o  other  form 
of  insanity  shows  this  alarming  result,  for  a  temperature  over 
100°  I  look  on  with  alarm  in  any  form  of  mental  disease. 
The  most  serious  part  of  it  is,  as  we  shall  see,  that  all  the 
deaths  occurred  in  the  cases  with  a  temperature  over  100°. 
Yet  to  show  that  a  high  temperature,  though  alarming,  is 
not  necessarily  prognostic  of  death,  I  find  that  of  the  five 
cases  where  it  was  over  103°  three  made  excellent  recoveries. 
I  lately  saw  a  case  in  private  practice  who  recovered,  and 
whose  temperature  had  been  over  105°.  The  causes  of  the 
high  temperature  differed  in  difi'erent  cases.  The  chief  causes 
were — (1)  simj)le  acute  brain  excitement  \  (2)  inflammation 
of  the  womb  and  surroundings,  in  some  cases  septic,  in  others 
simple  \  (3)  meningeal  inflammation  ;  (4)  incidental  causes, 
such  as  malaria,  mammary  abscess,  &c. 

Appetite. — The   most    common  and   one   of   the  most  im- 

1  From    96°  to    97°  in    3  cases.  From  101°  to  102°  in  3  cases. 
„       97°,,     98°  „  10     „  „     102°,,   103°,,  4      „ 

„       98°,,     99°  „  21     „  „     103°,,  104°,,  3      „ 

,,       99°  „  100°  ,,  12     ,,  „     104°,,  105°,,   1      ,, 

,,     100°,,  101°  „     2     ,,  ,,     105°,,  106%,   1      ,, 


PUERPERAL   INSANITY.  557 

portant  of  all  the  symptoms  present  was  tlie  refusal  of  food 
— paralysis  of  appetite.  In  thirty  cases,  or  50  per  cent., 
this-  was  present.  It  could  not  be  overcome  but  by  the  use 
of  the  stomach-pump  or  nose-tube  in  about  ten  cases.  In  a 
puerperal  case  refusing  food  I  now  use  forcible  feeding  at 
once  if  food  cannot  be  given  in  any  other  way.  In  no  other 
kind  of  mental  disease  has  the  doctor's  instructions  to  the 
nurse  to  be,  "  give  much  food  and  give  it  often."  I  am  quite 
sure  that  many  of  the  puerperal  cases  not  septicaemic  that  die 
at  home  or  in  asylums  die  from  want  of  early  feeding.  I 
give  stimulants,  too,  in  larger  quantities  with  the  food  than 
in  any  other  kind  of  insanity.  I  have  seen  the  greatest  and 
most  evident  good  results  from  large  doses  of  quinine  as  an 
antipyretic.  In  the  case  to  which  I  have  alluded,  where  the 
temperature  was  over  105°,  every  10-grain  dose  of  quinine  was 
followed  regularly  by  a  faU  of  from  2°  to  4°  of  temperature. 

Individual  Symptoms. — There  were  many  other  symptoms, 
mental  and  bodily,  very  common  besides  a  high  temperature. 
Tenderness  on  pressure  over  the  region  of  the  womb  was 
common,  and  whenever  it  is  present  I  am  in  the  habit  of 
ordering  carbolised  warm  water  vaginal  injections  and  warm 
sHghtly  counter-irritating  poultices  over  the  abdomen,  with 
sometimes  blistering  over  the  pubis.  Local  abscesses  in  the 
ankles,  fingers,  wrists,  and  body  occurred  in  some  cases. 
Muscular  jactitation  and  subsultus  occurred  in  some  of  the 
worst  cases,  but  were  not  always  followed  by  collapse. 
(Edema  and  albuminuria  were  present  in  two  cases,  and 
convulsions  in  one.  Of  the  mental  symptoms,  one  of  the 
most  important,  from  its  great  frequency,  was  the  suicidal 
impulse.  It  was  present  in  twenty-five  cases,  or  40  per  cent, 
of  the  whole.  It  was  present  in  an  impulsive  form  in  many 
of  the  maniacal  as  well  as  some  of  the  melancholic  cases. 
No  medical  man,  therefore,  in  treating  a  case  of  puerperal 
insanity,  but  should  keep  in  mind  that  the  patient  may 
attempt  suicide,  and  he  should  warn  the  nurses  and 
attendants  of  this. 


558  PUEKPEEAL  INSAlSlITy. 

The  presence  of  hallucinations  of  the  senses,  especially  of 
hearing,  I  was  surprised  to  find  so  common.  It  occurred 
in  at  least  one-third  of  the  cases,  and  was  often  very  per- 
sistent, as  hallucinations  of  hearing  are  apt  to  he,  after  the 
other  symptoms  were  passing  off.  But  this  did  not  indicate 
incurahility,  as  is  the  case  so  often  in  chronic  auditory  hallu- 
cinations of  alcoholic  origin. 

The  patients  in  many  cases  passed  from  the  acute  stage 
into  one  of  stupor,  and  in  some  this  existed  from  the  hegin- 
ning.  At  one  part  or  other  of  the  case  stupor  was  present 
in  at  least  fifteen  cases,  or  25  per  cent.  It  Avas  connected,  I 
fear,  in  some  of  them  with  the  habit  of  masturbation,  to 
which  puerperal  cases  are  very  subject.  IS'either  the  stupor 
nor  the  masturbation  indicate  incurability.  One  case  in 
which  both  were  the  most  prominent  symptoms  recovered. 

Curability. — The  last  and  most  important  point  brought  out 
in  this  study  of  these  sixty  puerperal  mental  cases  is  the  great 
curabihty  of  the  disease.  Thirty -three  cases  were  discharged 
recovered,  and  seventeen  were  discharged  much  improved. 
01  the  latter  the  prospects  of  complete  recovery  were  very 
good.  I  actually  knew  they  did  complete  their  recovery  in 
twelve  cases.  That  is,  forty-five  cases  out  of  the  sixty 
recovered,  which  amounts  to  a  recovery  rate  of  75  per  cent. 
Most  of  the  recoveries  took  place  quickly.  In  three  months 
from  the  beginning  of  the  attack  over  one-half  of  the  cases 
were  well,  and  in  six  months  90  per  cent,  of  those  who 
recovered .  were  well.  But  to  prevent  any  tiling  like  loss  of 
hope,  I  mention  that  one  of  the  melancholic  cases  with  stupor 
recovered  after  the  disease  had  existed  for  four  years.  Xo 
recoveries  from  mental  disease  are  generally  better  or  more 
satisfactory  than  those  from  puerperal  insanity.  In  some 
cases  recovery  was  very  rapid  indeed  after  it  began.  In  the 
cases  where  stupor  existed,  or  supervened  on  acute  insanity, 
the  occurrence  of  menstruation  seemed  often  to  act  as  the 
exciting  cause  of  recovery.  I  myself  believe  that  this  was 
mostly  a  coincidence,  or  rather  I  should  put  it  that  sanity 


PUERPEKAL  INSANITY.  559 

was  the  mental,  and  menstruation  a  cliief  bodily  symptom  of 
the  restoration  of  brain  and  body  to  their  normal  working. 
Itia  the  proper  mode  of  treatment,  however,  whenever  a 
puerperal  case  gets  strong  in  body  and  the  weight  becomes 
normal,  to  use  every  means  to  restore  menstruation  if  it  has 
not  returned.  "Warm  baths  at  night,  mild  shower  baths  in 
the  morning,  hip  baths  with  mustard,  aloes  and  iron  pills, 
and  borax  at  the  time  menstruation  is  expected,  are  all  use- 
ful in  addition  to  the  general  tonic  and  fresh  air  treatment. 
Menstruation  returning  before  the  general  strength  is  im- 
proved is  usually  a  bad  tiling,  for  it  is  apt  to  be  attended 
with  increased  mental  excitement,  and  is  apt  to  become 
menorrhagic. 

Looking  at  curability  of  the  cases  according  to  their 
characters  of  acuteness  or  mildness,  and  of  mental  exaltation 
or  depression,  I  find  that  the  forty-three  acute  cases  recovered 
in  the  proportion  of  81  per  cent.,  and  the  seventeen  mild  cases 
in  the  proportion  of  only  62  per  cent.  But  then  it  must  be 
kept  in  mind  that  the  mild  cases  were  longer  in  being  sent 
into  the  Asylum,  and,  of  the  total  number  of  mild  puerperal 
cases  occurring,  the  most  intractable  and  prolonged  would  be 
the  only  ones  sent  into  the  Asylum ;  the  rest  would  recover 
at  home.  Of  the  exalted  and  depressed  cases — mania  and 
melanchoha — an  almost  equal  proportion,  that  is  75  per  cent., 
of  each  recovered. 

Mortality. — Five  of  the  sixty  cases  died,  four  of  them  within 
a  month  of  the  onset  of  the  disease,  and  one  within  two 
months.  This  is  a  mortality  of  8 '3  per  cent,  of  the  cases. 
1^0  cases  are  more  difficult  to  get  post-mortem  examinations 
in  than  puerperal  cases,  and  they  were  performed  in  only 
three  of  the  five  cases.  The  cause  of  death  in  one  was  found 
to  be  phthisis  pulmonalls,  under  which  the  patient  had 
laboured  for  long  before  her  confinement,  and  which  as 
usual  advanced  rapidly  after  parturition;  in  another  it  was 
septicsemia;  and  in  the  third  simple  maniacal  exhaustion, 
without    symptoms    of    septicsemia.      There    is    no    doubt. 


560  LACTATIONAL   INSANITY. 

however,  that  the  chief  cause  of  death  in  puerperal  cases 
that  have  been  properly  fed  is  septicaemia.  They  are,  in  fact, 
cases  of  combined  puerperal  fever  and  puerperal  mania,  the 
mania  having  more  of  the  character  of  deHrium  than  of 
ordinary  insanity.  It  is  curious  that  there  was  no  history  of 
preliminary  chill  in  the  septicaemic  cases.  As  I  said,  I  do 
not  like  the  temperature  to  run  up  much  above  100°  in 
puerperal  cases.  Of  the  fourteen  cases  in  which  this  took 
place,  five  died,  or  35  per  cent.  I  still  less  like  to  see 
muscular  subsultus  with  a  restless  moving  of  the  hands  and 
twitching  of  the  facial  muscles.  There  may  be  septicaemia 
in  a  puerperal  case  with  purulent  peritonitis,  metritis,  and 
phlebitis,  and  yet  the  patient  never  complains  of  any  local 
pain,  and  even  on  pressure  there  may  be  no  uterine  or  peri- 
toneal tenderness.  Many  of  the  cases  with  the  worst  symp- 
toms, bodily  and  mental,  made  good  recoveries.^ 


LACTATIO^^AL  mSANITY. 

An  anaemic  insanity  ;  occurs  within  three  months  after  confinement,  or 
after  prolonged  lactation ;  risk  greatest  after  several  children  ; 
usuallj-  mental  symptoms  Melancholia  at  some  period  ;  some  cases 
Mania  ;  premonitory  symptoms  usually  present ;  headaches  ;  tinnitus 
aurium ;  flashes  of  light ;  irritability  ;  precordial  anxiety — Forms 
4  per  cent,  of  insanity  in  females  ;  rare  among  richer  classes — 
Prognosis :  Good ;  77  per  cent,  recover ;  duration  longer  than 
Puerperal  Insanity — Treatment :  Stop  nursing  ;  tonic  and  support- 

.      ing. 
Xursing  in  women  is  the  cause  of  mental  disease  sometimes. 

The  poor  are  more  Uable  to  this  than  the  rich,  both  being 

1  These  statistics  may  be  usefully  compared  with  and  supplemented 
by  Dr  J.  Batty  Tuke's  statistics,  obtained  from  an  analysis  of  cases  in 
this  Asylum,  in  the  Edinburgh  Medical  Journal  for  May  1865  ;  and  with 
those  of  Dr  Campbell  Clark's  papers  in  the  Lancet,  vol.  ii.,  1883,  and  in 
the  Jo)ir.  of  Mental  Science,  July  1887  ;  with  those  of  Dr  M.  Macleod's 
paper  in  the  Brit.  Med.  Jour,  for  August  7,  1886  ;  and  with  those  of 
Dr  Wiglesworth's  paper  in  the  Liverpool  Medico- CJiirurg.  Jour.,  1886. 
which  all  contain  important  additions  to  our  knowledge  of  the  subject. 


LACTATIONAL   INSANITY.  561 

equally  subject  to  puerperal  insanity.  This  is  as  might  be 
expected.  If  the  wife  of  a  labourer  has  had  ten  children  and 
nursed  them  all,  if  she  has  during  all  the  years  those  ten 
pregnancies  and  childbirths  and  nursings  have  been  going  on 
had  to  work  hard,  if  she  has  had  to  struggle  with  poverty  and 
insufficient  necessaries  of  life  in  addition  to  this  continuous 
reproductive  struggle  and  family  worries,  if  in  addition  to  all 
this  she  has  inherited  a  tendency  to  mental  disease,  no  physi- 
ologist or  physician  can  wonder  if  she  should  become  insane 
during  the  tenth  nursing.  Indeed,  the  wonder  is  that  any 
organism  could  possibly  have  survived  in  body  or  brain  such 
a  terrible  strain  and  output  of  energy  in  all  directions.  Such 
a  woman  often  enough  becomes  insane  during  a  nursing  long 
before  the  tenth.  An  organic  sense  of  duty  and  a  stern 
physiological  necessity  among  poor  women  compel  them  to 
nurse  their  offspring.  What  else  can  they  do  ?  It  is  well  for 
the  offspring,  but  the  neurotic  mother  often  enough  dies,  or  is 
upset  in  body  or  brain  in  the  attempt. 

Symptoms. — A  typical  case  of  lactational  insanity  is  one 
occurring  in  the  case  of  a  poor  woman  who  has  had  several 
children,  and  has  nursed  the  last  for  several  months,  who  has 
got  pale  and  thin  in  the  process,  and  has  become  subject  to 
headaches,  noises  in  her  ears,  giddiness,  flashes  of  light  before 
her  eyes,  lassitude  and  nervous  irritability,  in  fact  to  the  usual 
symptoms  of  general  bloodlessness  and  brain  anaemia.  She 
then  gets  depressed  in  mind,  her  sleep  leaves  her,  her  self- 
control  is  lost,  and  she  becomes  either  lethargic  and  stupid  or 
suicidal,  with  delusions  that  her  husband  and  neighbours  are 
against  her,  thereby,  poor  woman,  merely  misinterpreting  her 
sensations  of  mental  pain  and  distress.  She  had  little  organic 
strength  for  her  pregnancy,  still  less  for  her  delivery,  and  it 
has  quite  broken  down  in  her  nursing.  To  such  a  woman  the 
organic  dehght  of  suckling  her  infant,  for  which  the  maternal 
nature  craves  and  is  satisfied  by  the  process,  becomes  an  irrita- 
tion, an  excitement,  and  an  exhaustion.  But  such  a  typical 
case,  if  taken  in  time,  and  if  nursing  is  stopped  and   rest  is 

•2  N 


562  LACTATIONAL  INSANITY. 

given,  with  good  nourishing  food,  malt  Hquors,  and  iron,  cod- 
Hver  oil,  and  fresh  air,  at  once  begins  to  amend,  sleeps,  acquires 
self-control,  ceases  to  imagine  tilings  that  have  no  objective 
existence,  puts  on  flesh,  begins  to  employ  herself,  gets  cheerful, 
and  is  quite  well  and  strong  in  three  months,  her  blood  con- 
taining many  more  blood  corpuscles  than  it  had  when  treat- 
ment was  begun,  and  the  re-nourished  brain  resuming  all  its 
normal  functions  in  a  normal  way.  But  cases  of  lactational 
insanity  vary  greatly  in  form,  degree  of  mental  disturbance, 
and  duration  of  attack.  It  must  be  admitted  that  they  do 
not  follow  one  type.  They  are  nearly  all  melancholic  at  some 
period  of  the  attack.  They  nearly  all  suffer  from  premonitory 
neuroses  of  sensation  in  the  shape  of  headaches,  lassitude, 
neuralgia,'  feelings  of  sinking  at  pit  of  stomach,  or  some  of 
the  other  signs  of  anaemia  and  ill-nourishment.  They  are  a 
very  curable  class  if  put  under  proper  treatment  in  proper 
time. 

The  following  case  is  an  almost  typical  one,  except  that  the 
first  part  of  the  asylura  stage  of  it  ivas  more  acute  than  usual : — 
K.  J.,  set.  40,  the  wife  of  a  plumber  who  earned  when  in  full 
work  28s.  a  week,  has  had  seven  children  in  sixteen  years, 
and  nursed  each  about  fifteen  months.  There  is  no  known 
heredity  to  insanity.  She  nursed  the  last  child  for  twelve 
months,  and  of  course  had  to  do  her  family  duties  meanwhile. 
Her  first  symptoms  were  great  depression  and  want  of  energy. 
She  would  sit  for  hours  doing  notliing,  saying  nothing,  and 
taking  no  notice  of  anytliing.  Her  brain  seemed  to  have  been 
exhausted  in  its  power  to  energise  mentally.  Then  she  began 
to  be  restless  and  sleepless,  and  her  head  felt  sore  and  queer. 
Soon  she  became  delusional,  fancying  she  saw  friends  in  the 
street  who  were  in  the  colonies.  She  was  sent  at  first  to 
the  Royal  Infirmary,  but  proving  unmanageable  there  she 
was  sent  here.  On  admission  she  was  markedly  depressed, 
and  the  mental  working  of  her  brain  was  enfeebled  in  such  a 
way  that  she  would  begin  a  sentence  in  answer  to  a  question, 
and  would  stop  in  the  middle,  her  volitional  power  having 


LACTATIONAL  INSANITY.  563 

run  short  apparently.  She  rambled  in  speech  and  mistook 
the  identity  of  persons  round  her.  She  had  the  delusion  that 
she  was  to  be  burned  at  the  stake.  She  was  thin,  pale, 
muscularly  feeble,  lacking  in  energy,  with  blunted  sensibility. 
Her  special  senses  were  also  impaired,  pulse  small  and  weak, 
temperature  98*8°.  After  admission  she  was  sleepless,  rest- 
less, and  acutely  excited  for  a  week.  Then  she  became  more 
quiet,  with  short  intervals  of  almost  sanity,  but  with  impulsive 
action.  Sitting  quietly  sewing  in  a  room  with  others,  she 
would  suddenly  drop  on  her  knees  and  pray  aloud.  "Was  put 
on  extra  diet,  with  porter  and  quinine  and  iron.  She  always 
got  worse  and  more  delusional  in  the  evening,  this  fact 
probably  indicating  that  by  that  time  her  brain  power  was 
getting  exhausted.  But  she  steadily  picked  up  in  flesh  and 
strength,  mental  and  bodily,  and  in  ten  months  was  discharged 
almost  recovered,  having  gained  24  lbs.  in  weight,  and  looking 
fresh  and  healthy.  What  will  happen  if  she  has  more  children, 
and  nurses  each  of  them  fifteen  months,  can  easily  be  con- 
jectured. I  have  met  with  many  such  cases  as  the  above, 
sober  women  when  in  good  health,  taking  to  drink  when  the 
depression  first  came  on. 

Treatment. — The  treatment  of  lactational  insanity  is  simple 
and  physiological.  Stop  the  nursing,  give  nourishment  in 
abundance  with  some  malt  liquor,  change  the  scene,  free  the 
patient  from  family  cares  for  a  time,  give  quinine,  iron,  cod- 
liver  oil,  and  tonics  generally.  The  suicidal  tendency  must  be 
thought  of  and  guarded  against  if  present,  as  it  is  in  a  very 
large  proportion  of  the  cases. 

Statistics. — A  survey  of  my  nine  years'  chnical  experience 
in  the  Eoyal  Edinburgh  Asylum,  1874-82,  in  regard  to  lacta- 
tional insanity  is  instructive.  We  have  had  altogether  fifty- 
two  cases  that  I  classified  as  lactational.  But  some  of  these 
were  old  cases  of  the  disease  transferred  from  other  asylums, 
or  readmitted,  and  these  I  shall  take  no  notice  of.  Their 
study  would  lead  to  no  good  clinical  results,  and  would  merely 
tend  to  confusion.     Forty  of  the  cases  were  admitted  labouring 


564  LACTATIONAL  INSANITY.     • 

under  recent  lactational  insanity,  and  of  these  only  I  shall 
speak. 

OJiarader. — As  classified  on  admission,  twenty-one  of  these 
were  cases  of  mania  and  nineteen  of  them  of  melancholia. 
Only  about  half  of  these  twenty-one  cases  of  mania  had  mental 
exaltation  as  their  predominant  feature  throughout  their 
whole  course,  the  others  heginning  with  marked  melanchohc 
symptoms  or  ending  with  them.  But  the  fact  that  half  the 
cases  were  maniacal  during  their  most  acute  period  shows 
that  the  insanity  of  lactation  is  by  no  means  exclusively  a 
melanchohc  form  of  mental  disease.  It  shows  that  bodUy 
and  nervous  exhaustion  and  malnutrition,  though  their  first 
mental  symptoms  may  be  mental  depression,  yet  tend  in  a 
large  number  of  cases  towards  morbid  mental  exaltation  with 
excitement,  in  the  long-run,  mania  being  in  fact  another  and  a 
farther  stage  of  the  convolutional  brain  disturbance.  "WTien 
classified  according  to  the  acuteness  or  mildness  of  their 
symptoms,  independently  of  psychical  exaltation  or  depression, 
I  find  there  were  twenty-two  acute  cases  and  eighteen  mild 
ones,  the  majority  (eighteen)  of  the  acute  cases  being  maniacal, 
and  a  majority  (thirteen)  of  the  mild  cases  being  melancholic. 

Time  of  Occurrence. — As  regards  the  months  of  nursing 
in  which  the  disease  occurred,  my  records  do  not  state  this 
point  in  seventeen,  but  of  the  remaining  no  less  than  ten 
occurred  within  the  first  three  months,  seven  in  the  next 
three,  four  in  the  next  three,  and  only  two  in  the  last  three 
months.  I  confess  I  was  surprised  at  this.  It  is  a  different 
result  from  that  arrived  at  by  Dr  Batty  Tuke  from  an 
examination  into  the  statistics  of  fifty-four  cases  of  the 
insanity  of  lactation  that  had  been  in  this  Asylum  previous 
to  May  1865.  Only  two  of  his  cases  occurred  within  the 
third  month,  and  only  eight  within  the  first  six  months  of 
nursing,  while  twenty-one  cases,  or  51  per  cent,  of  those  in 
whom  the  period  was  recorded,  occurred  after  the  ninth 
month  of  nursing,  my  percentage  for  the  same  period  being 
nine.     My  statistics  distinctly  point  to  the  causation  of  this 


LACTATIONAL  INSANITY. 


565 


form  of  mental  disease  being  in  many  cases  due  to  the  dis- 
turbance of  the  puerperal  period  aggravated  by  the  reflex 
excitation  of  the  brain  through  the  physiological  act  of  suck- 
ling the  infants.  Dr  Tuke's  statistics  clearly  point  to  a  pre- 
ponderating causation  by  the  exhaustion  of  mere  long- 
continued  nursing.  Both  causes  operate,  I  have  no  doubt, 
but  why  they  should  have  operated  so  differently  in  the  cases 
in  the  same  asylum  at  different  periods  I  am  unable  to 
explain;  My  records  were  so  deficient  in  regard  to  which 
nursing  the  disease  occurred  in  as  to  be  worthless.  They 
merely  show  that  lactational  insanity  may  occur  after  the  first 
child  or  the  seventh.  The  suicidal  impulse  is  common,  seven- 
teen of  the  forty  having  had  it  in  greater  or  less  intensity. 

Temperature. — The  temperature  shows  a  very  marked 
difference  from  the  puerperal  form  of  insanity.^  A  glance  at 
the  liighest  temperatures  shows  that  only  about  one-third  of 
the  cases  (thirteen)  were  over  the  normal  standard,  and  of 
these  the  great  majority  (eight)  were  only  between  99°  and 
100°.  Three  were  between  100°  and  101°,  leaving  only  two 
that  were  over  that,  in  one  of  whom  it  was  caused  by  an 
inflamed  breast.  The  temperature  record  shows  clearly  the 
milder  type  of  lactational  insanity  as  compared  with  the 
puerperal  form.  The  thermometer,  though  the  readings 
seldom  reach  very  liigh  in  uncomplicated  mental  disease,  I 
look  on  as  being  simply  invaluable  as  showing  the  intensity 
of  the  brain  action.  Its  readings  upwards,  from  normal  to 
102°  or  103°,  are  usually  in  the  exact  ratio  to  the  intensity  of 
the  mental  disease.  Only,  it  must  be  remembered  that  half 
a  degree  in  the  estimation  of  the  intensity  of  brain  overaction 
is  equivalent  to  two  degrees  in  the  measurement  of  febrile 
disturbance.  I  attach  especial  importance  to  the  readings  of 
the  thermometer  in  all  acute  mental  diseases,  and  have  used 


^  From  96°  to    97°  in    1  case. 
„     97°  ,,    98°  „    6    „ 
„     98°  „     99°  „  20     „ 
„     99°  „  100°  „     8     „ 


From  100°  to  101°  in  3  cases. 
„      101°  „  102°  ,,  0     ,, 
„      102°  „  103°  ,,1      „ 
„      103°  „  104°  „  1      „ 


566 


LACTATIONAL  INSANITY. 


it  in  every  case  under  my  care  in  the  Carlisle^  and  Eoyal 
Edinburgh  Asylums  since  the  year  1866. 

Heredity. — Heredity  to  insanity  was  known  to  be  present 
in  fifteen  of  the  cases  ;  but  then  in  twelve  of  the  forty  no  re- 
liable information  on  this  point  could  be  got.  And  as  proxi- 
mate causes,  mental  and  normal  disturbances  occurred  in  nine 
of  the  cases. 

Curability. — Let  us  look  now  at  the  results  of  treatment, 
the  most  interesting  of  all  questions  to  the  physician,  and 
still  more  so  to  the  relatives  of  the  patients.  Thirty-one  of 
the  forty  cases  recovered,  and  three  more  were  removed  from 
the  Asylum  uncured  but  improving.  This  is  77|  per  cent,  of 
actual  recoveries,  and  a  still  higher  figure  of  potential  restora- 
tions to  mental  health.  The  lactational  cases  recovered  in 
sHghtly  larger  numbers  therefore  than  the  puerperal  cases, 
and  only  one  case  of  the  forty  died.  I  find  that  the  maniacal 
and  the  melancholic,  the  acute  and  the  mild  cases  recovered 
in  somewhat  equal  proportions.^  The  six  who  did  not  get 
better,  but  are  still  under  treatment,  were  three  of  them 
patients  who  had  repeated  attacks  of  insanity  before,  the 
other  three  looking  phthisical.  The  lactational  cases  did  not 
recover  as  soon  as  the  puerperal.^  Only  sixteen  recovered 
within  three  months,  but  twenty-five,  or  62  per  cent,  of  all 
the  cases,  and  80  per  cent,  of  the  recoveries,  recovered  within 
six  months,  and  all  of  them  within  eighteen  months.  And 
they  made  good  and  lasting  recoveries,  few  of  them  relapsing. 
Kecovery  in  all  the  patients  was  accompanied  by  a  great  in- 

^  See  author's  paper,  "Observations  on  the  Temperature  of  the  Body 
iu  the  Insane,"  Jourmd  of  Mental  Science,  April  1868. 

-  Of  the  twenty-one  cases  of  mania  fifteen  recovered  ;  of  the  nineteen 
cases  of  melancholia  sixteen  recovered  ;  of  the  twenty-two  acute  cases 
fifteen  recovered  ;  and  of  the  eighteen  mild  cases  sixteen  recovered. 


^  Within  1  month  6  cases  recovered. 

Within 

7  months  1  case 

recovered 

2 

M        6 

j> 

8 

,j 

1 

>) 

3 

,,       4 

>> 

9 

,, 

2 

)> 

4 

,,      2               „ 

5> 

11 

>) 

1 

,, 

5 

»,      6               ,, 

>) 

18 

;5 

1 

)> 

6 

„       1 

THE   INSANITY   OF   PREGNANCY.  567 

crease  in  tody- weight,  in  strength,  in  appetite,  and  in  fatness. 
In  some  menstruation  continued  during  the  disease,  and  in  its 
earher'  stages  produced  excitement  and  exhaustion  of  strength. 
It  was  often  menorrhagic  in  such  cases.  The  function,  when 
absent,  usually  returned  of  itself  without  any  special  treat- 
ment, as  the  nutrition  improved. 

Effect  of  Patient's  Circumstances. — One  instructive  fact  I 
came  across  in  relation  to  this  disease.  Out  of  166  admissions 
of  ladies  to  our  liigher-class  departments  there  were  only 
two  lactational  cases,  while  there  were  among  them  the  usual 
proportion  of  puerperal  cases.  Out  of  1383  pauper  and 
poorer  private  female  patients,  there  were  thirty-eight  lacta- 
tional cases.  In  short,  the  puerperal  cases  were  sent  for 
hospital  treatment  in  as  great  a  proportion  among  the  rich 
as  the  poor,  while  the  lactational  cases  were  only  sent  in 
half  that  proportion.  This  points  clearly  to  the  greater 
mildness  of  type  of  the  latter,  and  the  possibility  of  treating 
it  at  home,  if  not  to  the  greater  infrequency  of  the  disease 
among  the  well-fed  classes,  who  have  servants  to  work  for 
them,  nurses  to  attend  their  children,  and  doctors  to  tell 
them  when  to  stop  nursing  in  time.  Probably  the  custom 
among  the  poor  of  nursing  each  child  a  long  time  in  order  to 
delay  the  conception  of  the  next  has  something  to  do  with  the 
greater  prevalence  of  this  form  of  mental  disease  among  them. 


THE  mSAMTY  OF  PREGI^AN"CY. 

Rare  ;  1  per  cent,  of  insanity  among  women  ;  occurs  most  frequently  in 
women  advanced  in  life  when  pregnant ;  usually  melancholic  ; 
suicidal  tendency  in  half  the  cases  ;  connection  of  the  insanity  with 
the  morbid  cravings,  &c.,  of  pregnancy  ;  a  few  cases  of  stupor  ;  a 
few  of  dipsomania — Most  cases  recover  at  childbirth  ;  60  per  cent.  ; 
a  few  rapidly  become  demented. 

Few  women  carry  a  child  Avithout  being  influenced  mentally 
thereby  in  some  way  or  other.     The  psychology  of  pregnancy 


568  .THE   INSANITY  OF  PEEGNANCT. 

has  yet  to  be  written  in  a  scientific  way.  There  are  innumer- 
able facts  on  record,  but  they  are  scattered  and  undigested. 
Without  going  into  the  domain  of  mental  disease  in  any 
technical  sense,  we  find  examples  of  partial  mental  exaltation, 
mental  depression,  mental  enfeeblement,  mental  paralysis, 
and  mental  perversion.  No  doubt  the  alterations  are  chiefly 
in  the  afi"ective  faculties,  but  the  reasoning  power,  the  moral 
sense,  the  volitional  power,  the  imagination,  and  even  the 
memory,  are  often  enough  afi"ected  in  pregnant  women.  As  a 
part  of  the  nervous  disturbances,  the  bodily  appetites  become 
changed,  the  physiological  functions  altered,  and  the  nutrition 
of  organs  profoundly  affected.  In  this  state  many  women 
have  endless  caprices,  unfounded  dislikes  and  likings,  cravings 
for  foods  and  drinks  never  before  desired,  unnatural  desires 
for  indigestible  things,  causeless  weeping  and  laugliing, 
stealing  and  lying,  morbid  thirst  and  hunger,  an  activity 
of  digestion  never  before  known,  pigmentation  of  the  skin, 
alteration  of  the  expression  of  the  face,  of  the  tones  of  the 
voice,  and  of  the  power  of  muscular  co-ordination.  It  is 
scarcely  surprising  that  every  function  of  the  great  central 
nervous  system  should  be  thus  affected  in  many  cases,  for, 
physiologically,  pregnancy  means  a  dynamical  change  for  the 
time  being  in  the  direction  of  some  of  the  great  currents  of 
energy,  and  a  change,  amongst  others,  in  the  quality  of  the 
blood.  Psychologically  it  is  the  fulfilling  of  the  second 
strongest  organic  necessity  of  hfe — to  reproduce  the  species. 
All  the  changes,  mental  and  bodily,  that  I  have  referred  to,  and 
far  more  than  these,  should  be  taken  into  account  in  studying 
the  question  of  how  pregnancy  produces  those  great  psychical 
disturbances  that  we  call  insanity  in  brains  predisposed  there- 
to. A  considerable  number  of  women  are  mentally  unsound 
during  pregnancy,  if  judged  by  an  ideal  standard  of  volitional 
power,  while  very  few  indeed  pass  the  conventional  line 
that  divides  sanity  from  insanity.  N'ature  seems  to  care  for 
pregnant  women  physiologically  in  all  directions,  and  does 
so  in  the  case  of  the  mental  functions  of  the  brain  convolu- 


THE   INSANITY   OF   PREGNANCY.  569 

tions.  Those  may  be,  and  are  often,  slightly  affected  in  preg- 
nancy, but  are  seldom  quite  upset.  It  is  a  very  rare  form,  as 
an  insanity,  as  we  shall  see  from  the  statistics.  In  fact,  there 
is  no  period  in  the  life  of  a  woman  after  the  age  of  25  when 
she  is  less  liable  to  actual  insanity  than  during  her  pregnancies. 
But  there  is  an  infrequent  type  of  case  exactly  the  contrary 
of  this  rule,  where  a  woman  cannot  become  pregnant  without 
becoming  insane.  I  have  such  a  patient  now,  K.  K.,  who  has 
been  five  times  pregnant  and  five  times  insane,  each  time  during 
pregnancy.  This,  no  doubt,  is  the  clearest  indication  nature 
could  give  that  such  a  woman  should  never  become  pregnant.  I 
had  one  patient,  K.  L.,  who  had  six  different  attacks  of  insanity 
— ^two  of  pregnancy,  two  puerperal,  and  two  of  lactation — and 
she  made  perfect  recoveries  from  them  all,  though  in  each  she 
was  most  determinedly  suicidal  and  homicidal,  strangling 
and  killing  her  first  child,  and  attempting  at  least  six  different 
times  to  take  away  her  own  life.  Yet  for  the  last  eleven 
years  she  has  kept  quite  well,  and  done  her  work  at  home. 
She  had  one  or  two  other  children  without  being  affected  in 
mind  more  than  by  a  little  depression. 

Sym-ptoms. — The  typical  mental  disturbance  of  pregnancy 
of  the  mild  kind  not  requiring  asylum  treatment,  and  often 
not  incapacitating  a  woman  from  doing  her  duties,  consists  of  a 
mental  depression,  or  mental  apathy  not  amounting  to  stupor, 
with  a  loss  of  interest  in  things,  a  loss  of  conscious  affection 
for  husband  and  sometimes  for  children,  a  slight  weariness  of 
life,  a  fear  of  something  going  to  happen,  and  a  general  loss 
of  courage  and  a  disinclination  for  social  intercourse.  These 
symptoms  do  not  usually  come  on  before  the  third  month 
of  pregnancy,  and  much  more  frequently  they  do  not  come 
on  till  after  the  sixth  month.  Sometimes  they  only  last  for 
a  part  of  the  period  of  pregnancy  and  then  pass  off.  More 
usually  they  do  not  disappear  till  after  delivery.  They  either 
do  so  then  or  become  aggravated  into  a  more  acute  puerperal 
psychosis.  There  is  another  distinct  type  of  case  where  during 
the   first  pregnancy  insanity  comes  on,  becomes   acute,  and 


570  THE   INSANITY  OF  PREGNANCY. 

ends  in  dementia  soon.  This  is  perhaps  one  of  nature's  ways 
of  ending  a  bad  stock;  just  as  I  look  on  the  insanity  of  adoles- 
cence to  be,  and  on  sterility  to  be  in  some  cases,  and  on 
sexual  antipathy  to  be,  and  on  absence  of  the  social  instincts 
to  be.  There  are  psychological  bachelors  and  old  maids,  born 
so,  whom  no  social  cultivation  or  opportunity  can  make  other- 
wise, and  these  will  be  found  to  occur  usually  in  families  with 
a  heredity  to  insanity. 

The  following  euse 'presents  the  most  common  type  that  family 
doctors  have  to  do  with : — K.  M.,  a  married  woman,  set.  34, 
with  an  insane  heredity,  who  had  had  five  children  comfort- 
ably, came  to  me  saying  she  was  dull  and  miserable,  and 
could  not  do  her  work  nor  take  an  interest  in  anything.  It 
seemed  as  if  she  did  not  care  for  her  husband,  nor  to  do  her 
household  duties,  and  she  said  she  was  afraid  of  herself, 
meaning  that  she  might  commit  suicide.  She  was  stout, 
strong,  and  well  nourished,  and  looked  the  picture  of  good 
health.  She  slept  well,  ate  well,  and  all  her  bodily  functions 
were  normal.  She  was  in  the  sixth  month  of  pregnancy,  and 
the  mental  change  had  come  on  a  month  before.  I  advised 
that  she  should  have  a  female  friend  with  her,  and  should  go 
on  doing  her  work,  should  walk  much  in  the  fresh  air,  and 
wait  patiently  for  her  confinement.  After  the  eighth  month 
she  felt  much  better,  and  after  confinement  every  trace  of  her 
mental  depression  left  her. 

The  folloiving  loas  a  very  acute  case  of  the  insanity  of  preg- 
nancy : — K.  jST.,  set.  32,  pregnant  of  an  illegitimate  child, 
became  at  the  sixth  month  dull  and  apathetic,  then  within 
a  month  incoherent,  talkative,  and  almost  dehrious.  She  would 
moan  at  times  as  if  in  pain;  would  say,  poor  soul,  "I  am  in  a 
fearful  state;  never  was  in  such  a  state  as  this."  She  had 
hallucinations  of  sight,  seeing  elephants  all  of  a  green  colour 
before  her.  She  was  very  weak  on  admission,  could  not 
walk  well  without  assistance,  her  tongue  and  mouth  tended  to 
be  dry,  she  had  pain  in  her  abdomen,  her  ankles  were  swollen, 
her  pulse  was  136   and  weak,  and  her  temperature  100'4°. 


THE  INSANITY  OF   PREGNANCY.  571 

She  continued  restless,  depressed,  excited,  and  sleepless,  and 
eight  days  after  admission  was  delivered  of  a  healthy  male 
child.  -  Her  mental  state  improved  much  thereafter  for  a 
week,  when  she  had  a  relapse.  In  fact,  the  puerperal  state 
caused  an  excess  of  puerperal  insanity,  but  in  four  weeks 
after  the  birth  of  the  child  the  excitement  had  passed  off,  the 
delusions  only  remaining.  In  another  week  the  delusions  too 
had  left  her,  and  in  two  months  she  was  discharged  strong  in 
body  and  well  in  mind. 

The  next  is  a  more  characteristic  case,  K.  0.,  set.  30,  a 
married  woman  with  a  hereditary  history  of  insanity,  and 
pregnant  with  her  first  child,  became  insane  six  weeks  before 
its  birth ;  a  fear  came  over  her  first,  and  she  said,  "  I  must 
die,  I  must  die."  An  inflammation  in  one  lung  had  reduced 
her  strength,  and  she  had  been  sleepless  for  two  weeks, 
soporifics  having  no  effect.  She  was  suicidal,  and  tried  to 
jump  out  of  a  window.  Her  friends  properly  kept  her  at 
home,  nursing  and  looking  after  her  as  best  they  could  till 
the  child  was  born.  She  then  got  much  worse  mentally, 
and  remained  maniacal  for  two  months.  Then  she  became 
apathetic,  confused,  and  childish,  with  occasional  impulsive 
spurts  of  maniacal  excitement.  This  state  lasted  for  a  month, 
then  she  began  to  improve,  and  was  well  in  six  weeks,  her 
attack  having  lasted  altogether  five  months.  The  bromides 
and  iron  were  used  largely  in  the  acute  stage  of  her  disease, 
strychnine  in  the  apathetic  stage,  and  extra  food  and  fresh 
air  and  good  nursing  throughout.  There  was  a  very  decided 
tendency  to  stupor  during  some  part  of  this  case. 

Statistics, — The  cases  of  the  insanity  of  pregnancy  of  such 
an  acute  type  as  to  need  asylum  treatment  are  rare,  and 
by  no  means  of  a  uniform  type.  I  have  had  only  fifteen 
such  in  the  past  nine  years  sent  to  the  Royal  Edinburgh 
Asylum.  Nine  of  these  were  maniacal  and  six  melanchoHc  ; 
nine  of  an  acute  type,  and  six  were  mild  in  their  symptoms  ; 
seven  of  them  loere  suicidal,  some  being  desperately  so. 
This   is  an   enormous  proportion  of  suicidal  cases  for   amj 


572  THE  INSANITY  OF   PREGNANCY. 

kind  of  insanity.     In  half  of  those  with  a  history  there  was 
heredity  to  insanity,  mostly  strong  and  direct  heredity. 

Curability. — Of  the  fifteen  cases  only  nine  recovered,  or 
60  per  cent,  of  the  whole,  this  form  of  mental  disease  in  its 
worst  forms  being  thus  more  incurable  than  the  insanities 
of  childbed  or  nursing.  The  time  of  recovery  in  relation- 
ship to  confinement  was  various.  In  only  two  cases  of  the 
nine  who  recovered  was  the  termination  of  pregnancy  attended 
with  speedy  and  marked  mental  recovery.  In  four  cases  con- 
finement distinctly  aggravated  the  previously  existing  mental 
disease.  In  three  of  these,  in  fact,  the  symptoms  had  not 
been  so  bad  before  confinement  as  to  need  asylum  treatment 
at  all.  The  puerperal  state  seemed  to  bring  the  insanity  of 
pregnancy  to  a  climax  in  those  cases.  In  three  cases  of  the 
nine  who  recovered  they  got  better,  and  were  discharged 
from  the  Asylum  recovered  before  they  were  confined.  The 
whole  nine  had  recovered  in  six  months.  Three  cases  were 
transferred  to  other  asylums,  within  four  months  after 
admission,  in  an  improved  condition,  and  of  these  one  might 
possibly  have  got  better  ultimately,  and  one  was  taken  home 
before  recovery  and  did  get  quite  well.  This  would  bring 
up  the  recovery  rate  to  73  per  cent.  Two  died,  one  of 
ursemic  poisoning — this  probably  having  been  the  real  cause 
of  her  insanity — seven  days  after  admission,  and  another  of 
general  tuberculosis  in  ten  months. 

First  Pregnancies. — "Women  are  more  Hable  to  become  in- 
sane during  the  first  than  subsequent  pregnancies,  for  seven 
of  the  fifteen  cases  were  first  pregnancies ;  and  the  fact  that 
five  of  the  fifteen  were  iUegitimate  children  shows  that  moral 
causes  tend  to  bring  on  the  disease. 

Onset. — The  coming  on  of  the  disease  was  gradual  in  most 
of  the  cases,  and  it  began  in  all  but  two  with  depression  of 
mind  or  apathy  and  stupor.  The  afi'ection  towards  their 
husbands  became  perverted  in  nearly  all  the  married  cases. 
The  psychology  of  the  afi'ection  between  husband  and  wife, 
and  the  way  it  is  influenced  by  sexual  intercourse,  by  preg- 


THE   INSANITY  OF   PREGNANCY.  573 

nancies,  by  the  children  or  the  absence  of  children,  by 
neurotic  constitution  of  brain,  by  the  climacteric,  and  by  old 
age,  iias  yet  to  be  written  from  the  physiological  point  of 
view.  Many  strange  chapters  on  this  subject  could  family 
doctors  write.  I  have  not  had  a  single  case  of  the  insanity 
of  pregnancy  in  a  rich  patient  sent  here.  This  is  natural 
and  proper,  for  if  any  kind  of  mental  disease  should  be  kept 
out  of  asylums  without  sacrificing  life  or  recovery  it  is  this. 
It  would  be  a  terrible  fate,  as  tilings  go  in  this  world,  to 
be  born  in  a  lunatic  asylum,  in  addition  to  being  the  child 
of  an  insane  mother.  The  asylum  c^ses  can  scarcely  be 
taken  as  the  real  type  of  the  insanity  of  pregnancy,  they 
being  by  far  the  worst. 

Treatment. — The  treatment  of  the  insanity  of  pregnancy  is 
in  no  way  special.  The  women  are  not  usually  run  down. 
The  temperature  in  only  four  of  my  cases — one  being  the 
uraemic  case — was  above  99°.  Fresh  air,  exercise,  watching, 
nursing,  employment,  cheerful  society,  change,  freedom  from 
too  much  work  and  worry,  and  suitable  food,  are  about  all 
we  can  do.  Slight  sedatives  may  be  required  as  placebos,  but 
in  as  small  doses  and  as  seldom  as  possible.  The  blood  of 
an  insane  mother  needs  not  to  be  mixed  with  morphia  or 
chlol'al  to  make  it  bad  for  her  unborn  progeny.  The  ten- 
dency to  suicide  must  be  especially  kept  in  mind.  One  of 
my  cases  had  a  secondary  syphiKtic  eruption,  and  needed 
treatment  for  that,  and  in  two  more  I  suspected  syphilis, 
both  children  being  prematurely  dead-born. 

Frequency. — Together,  the  insanities  of  childbed,  nursing, 
and  pregnancy  have  constituted  over  9  per  cent,  of  all  the 
female  cases  in  the  Eoyal  Edinburgh  Asylum  for  the  past 
nine  years  (1874-82),  there  being  141  cases  out  of  1549 
admissions  (including  readmissions).  There  was  5  per  cent, 
of  the  puerperal  form,  4  per  cent,  of  the  lactational,  and 
1  per  cent,  of  the  insanity  of  pregnancy.  As  we  admit  all 
classes  of  society,  this  may  be  taken  to  represent  the  real 
effect  of  child-bearing  in  the  production  of  insanity,  at  least 


574  THE   INSANITY  OF   PREGNANCY. 

in  this  part  of  the  country.  In  Cumberland  and  Westmore- 
land, for  the  ten  years  (1863-72)  during  which  I  was  in 
charge  of  the  Carhsle  Asylum  (for  the  poorer  classes  only), 
there  were  75  cases  out  of  431  female  patients  in  all,  or  17 '4 
per  cent.  This  enormous  difference  of  nearly  twice  the 
proportion  is  made  up  entirely  of  the  excess  of  puerperal 
cases,  there  having  been  51  of  these,  or  11*8  per  cent,  of  the 
whole  of  the  female  insane  of  those  two  counties.  That  is 
more  than  twice  the  Edinburgh  proportion.  Such  great 
differences  in  the  local  distribution  of  the  diflferent  forms  of 
insanity  form  an  interesting  problem  in  medico-psychology 
that  needs  yet  to  be  worked  out  as  to  its  causes. 


LECTUEE   XVI. 

THE    IN"SANITIES    OF    PUBERTY    AND    ADOLES- 
CENCE {THE  DEVELOPMENTAL  INSANITIES). 

Enormous  differences  in  the  physiological  activities  of  the  brain  at 
different  periods — Type  of  mental  derangement  much  influenced  by 
the  special  physiological  activity  or  decadence  of  the  period — The 
developmental  insanities  and  those  of  decadence  —  Insanity  of 
Puberty  :  Rare  ;  only  2  cases  in  Royal  Edinburgh  Asylum  at  ages  of 
14  and  15  out  of  1800  cases,  and  only  22  at  16  and  17  ;  always 
hereditary  ;  acute  ;  remittent  ;  not  dangerous  to  life  ;  maniacal  ; 
theories  and  practices  of  education  at  puberty — Prognosis :  Good — 
Treatment :  Tonics  ;  fresh  air  ;  baths  ;  milk  and  farinaceous  diet  ; 
cod-liver  oil ;  bromide  of  potassium  ;  no  opium  or  chloral — Insanity 
of  Adolescence  :  Meaning  of  Adolescence — Physiological  and  psycho- 
logical characteristics  ;  momentous  period  ;  far  more  so  than  puberty 
— Novelists  the  best  students  and  describers  of  the  mental  character- 
istics, of  adolescence  ;  Gwendolen  Harleth  {Daniel  Deronda) — Rela- 
tionship of  adolescence  to  emotion,  sense  of  duty,  capacity  for  work, 
sentiment,  religious  sense,  courtship,  engagements  to  marry,  sexual 
intercourse — Of  1800  cases,  230  uncomplicated  between  14  and  25  ;  of 
these  49  occurred  at  the  ages  of  18,  19,  and  20,  while  157  occurred 
from  21  to  25 — Mental  Symptoms  :  78  per  cent,  exaltation  ;  only  22 
per  cent,  depression  ;  mania,  acute,  remittent,  relapsing  in  66  per 
cent.  ;  hereditary  predisposition  very  common  (45  per  cent,  ascer- 
tained, far  more  than  that  in  reality) ;  morbid  ideas,  emotions, 
speech,  and  conduct  tinctured  by  erotic,  sexual,  or  adolescent 
characteristics — Prognosis :  Good  ;  66  per  cent,  recover ;  relapses 
often  occur  in  after  life  ;  remainder  mostly  become  demented  and 
live  long,  bodily  health  often  being  good — Mortality  Small :  only 
1'8  per  cent,  died — Treatment:  Same  as  for  insanity  of  puberty— 
Signs  and  Accompaniments  of  Recovery :  Perfect  development  of 
form  and  mammae  ;  growth  of  beard  and  sexual  hair ;  change  of 
voice  ;  psychologically  and  physiologically  they  emerge  from  attack 
men  and  women. 


576    THE   INSANITIES  OF   PUBERTY  AND  ADOLESCENCE. 

When  one  considers  the  enormous  differences  in  the  physio- 
logical life  and  prevailing  brain  activity  of  the  same  human 
being  at  the  different  periods  of  life,  it  does  not  seem  wonder- 
ful that  each  period  has  its  own  type  of  psychological  dis- 
turbances, just  as  it  has  its  special  kinds  of  ordinary  disease. 
Indeed,  it  would  be  very  wonderful  if  the  brain  of  a  child, 
whose  chief  characteristics  are  active  growth,  intense  inquisi- 
tiveness  in  all  directions,  great  sensitiveness  to  impres- 
sions, wliich  succeed  each  other  rapidly,  and,  whether  they 
are  painful  or  pleasurable,  leave  only  slight  lasting  traces, 
if  tliis  organ  manifested  quite  the  same  disturbances  when 
its  mental  functions  become  deranged  as  the  brain  of  an  old 
man,  whose  chief  characteristics  are  retrogression  in  all  its 
activities,  and  insensitiveness  to  ordinary  impressions.  The 
essential  qualities  of  the  two  organs  are  in  many  respects 
different ;  their  prevaihng  receptive,  dynamical,  and  trophic 
activities  are  dissimilar.  Then  what  a  change  in  the  mental 
activity  of  the  brain  does  the  period  of  puberty  cause ! 
Looking  at  the  matter  from  the  combined  point  of  view 
of  physiologists  and  psychologists,  we  must  connect  the 
new  development  of  the  affective  faculties,  the  new  ideas, 
the  new  interests  in  Hf e,  the  new  desires  and  organic  cravings, 
the  new  delight  in  a  certain  sort  of  poetry  and  romance,  with 
a  new  evolution  of  function  in  certain  parts  of  the  brain  that 
had  lain  dormant  before.  This  awakening  into  intense 
activity  of  such  vast  tracts  of  encephalic  tissue,  though 
provided  for  in  the  evolution  of  the  organ,  does  not  take 
place  without  risk  of  disturbance  to  its  mental  functions, 
especially  where  there  is  an  inherited  predisposition  in  that 
direction.  And  if  this  predisposition  is  thus  developed  into 
actual  derangement  of  function,  it  happens,  as  might  have 
been  surely  predicted  a  priori,  that  the  type  of  derangement 
is  much  influenced  by  the  great  function  of  the  reproduction 
of  the  species  then  arising  de  novo.  To  form  a  right  con- 
ception of  the  kinds  of  mental  disease  that  occur  at  the 
various  important  periods  of  Hfe  it  is  essential  that  we  con- 


THE   INSANITIES   OF   PUBEKTY   AND   ADOLESCENCE.     577 

sider  them  in  connection  with  the  normal  changes  that  take 
place  in  the  organism  at  those  periods,  with  the  normal 
modific9,tions  in  the  mental  energy  at  those  periods,  and 
with  the  changes  that  take  place  in  the  brain  texture  and 
mode  of  action,  so  far  as  we  know  them.  In  short,  we  must 
take  a  physiological  view  of  mental  disease. 

The  Period  of  Puberty  or  Pubescence.— The  period  of 
puberty  is  the  next  great  physiological  era  in  the  life  of  man 
after  that  of  birth.  Before  that  occurs  the  whole  trophic  and 
mental  energy  has  been  occupied  in  acquisition  alone.  The 
brain  has  been  growing  in  bulk,  rather  than  developing  in 
higher  function.  There  has  been  no  production.  Before 
that  time  there  has  been  a  general  psychical  hkeness  between 
individuals  of  the  same  and  of  opposite  sexes  which  then 
rapidly  disappears.  Individualities  of  all  kinds  spring  up 
far  more  decidedly  at  that  time  in  those  of  the  same  sex  ; 
while,  dividing  the  sexes  at  this  time,  there  arise  most 
striking  psychical  differences  that  far  exceed  the  bodily 
contrasts.  Up  to  that  time  the  mental  development  of  each 
sex  has  been  very  much  in  the  same  direction ;  after  puberty 
that  development  takes  place  in  the  man  far  more  in  the 
direction  of  energising  and  cognition,  in  the  woman  in  the 
direction  of  emotion  and  the  protective  instincts.  But  these 
changes  do  not  ordinarily  take  place  all  at  once  in  the  human 
species,  any  more  than  a  full  capacity  for  reproduction  takes 
place  in  either  sex  immediately  the  testes  assume  their 
function,  or  menstruation  and  ovulation  are  set  up.  It 
takes  several  years  for  the  full  development  of  the  size  and 
form  of  the  body  that  is  normal  and  typical  for  each  sex, 
and  it  takes  still  longer  for  the  complete  evolution  of  the 
mascuhne  and  feminfne  psychical  characteristics.  It  is  not 
at  the  time  of  the  first  appearance  of  the  reproductive 
function  that  there  is  the  chief  peril  to  the  healthy  mental 
balance,  but  it  is  the  after  years  of  gradual  coming  to  maturity 
that  are  often  full  of  danger  to  the  mental  health  of  both 
sexes.     It   cannot  be  otherwise.     The   hereditary  influences 

2  0 


578    THE   INSANITIES   OF   PUBERTY    AND   ADOLESCENCE. 

and  tendencies  tliat  all  the  former  generations  have  trans- 
mitted to  a  man  come  then  most  fully  into  play.  And  when 
we  consider  for  a  moment  that  it  is  not  only  his  father's  and 
his  mother's  own  inherited  tendencies  that  may  come  to  him, 
hut  some  of  their  acquired  pecuHarities  as  well,  and  not  only 
so,  hut  the  inherited  and  acquired  peculiarities  of  his  four 
grandparents  and  his  eight  great-grandparents,  not  to  go  any 
further  hack,  how  great  a  risk  does  every  man  and  woman 
run  of  suffering  for  the  sins  of  their  fathers !  Maudsley 
speaks  of  a  man's  yielding  to  the  tyranny  of  his  organisation. 
We  might  go  further,  and  say  he  may  fall  a  victim  to  his 
grandfather's  excesses.  Most  fortunately  for  the  race,  there 
are  other  influences  obviating  such  effects  of  heredity.  One 
is  that  the  tendency  towards  reproducing  the  normal  and 
healthy  type  is  generally  stronger,  if  the  conditions  are 
favourable,  than  towards  the  abnormal.  If  the  conditions 
of  life  are  favourable,  mere  tendencies  never  develop,  and 
potentialities  never  become  actuahties.  The  other  is,  that 
when  the  tendency  to  abnormality  is  strong,  the  victim  of  it 
often  is  idiotic  or  sexually  unattractive,  dies  before  the  age 
of  reproduction,  or  he  is  incapable  of  procreation.  ISTow, 
the  insanity  of  puberty  is  always  a  strongly  hereditary 
insanity ;  it,  in  fact,  never  occurs  except  where  there  is  a 
family  tendency  towards  mental  defect  or  towards  some 
other  of  the  neuroses.  Its  immediate  cause  may  be  some 
irregularity  in  the  coming  on  of  the  reproductive  or  menstrual 
function ;  its  real  and  predisposing  cause  is  heredity,  having 
for  its  object  this  higher  physiological  law,  that  the  repro- 
duction of  the  species  tends  to  stop  when  the  inherited 
tendency  to  brain  disease  acquires  a  certain  strength  in  any 
individual. 

I  cannot  help  here  adverting  to  some  absurd  and  unphysio- 
logical  theories  of  education  which  are  common,  and  which 
we  as  medical  men  should  combat  with  all  our  might.  The 
theory  of  any  education  worth  the  name  should  be  to  bring 
the  whole  organism  to  such  perfection  as  it  is  capable  of,  and 


THE   INSANITIES   OF   PUBERTY  AND   ADOLESCENCE.     579 

to  train  the  brain  power  in  accordance  with  its  capacity,  most 
carefully  avoiding  any  overstraining  of  weak  points — and  an 
apparently  strong  point  in  the  brain  capacity  of  a  young 
child  may  in  reality  be  its  weakest  point  in  after  life.  I  hate 
known  a  child  with  an  extraordinary  memory  at  eight  who 
at  fifteen  could  scarcely  remember  anything  at  all.  Then,  as 
the  age  of  puberty  approaches,  one  would  imagine,  to  hear 
some  scholastic  doctrinaires  talk,  that  it  was  the  right  thing 
to  set  ourselves  by  every  means  to  assimilate  the  mental 
faculties  and  acquirements  of  the  two  sexes,  to  fight  against 
nature's  laws  as  hard  as  possible,  and  to  turn  out  psychically 
hermaphrodite  specimens  of  humanity  by  making  our  young 
men  and  women  alike  in  all  respects, — to  make  our  girls 
pundits  and  our  young  men  mere  examination-passers.  If 
there  is  anything  which  a  careful  study  of  the  higher  laws  of 
physiology  in  regard  to  brain  development  and  heredity  is 
fitted  to  teach  us,  it  is  this,  that  the  forcing-house  treatment 
of  the  intellectual  and  receptive  parts  of  the  brain,  if  it  is 
carried  to  such  an  extent  as  to  stunt  the  trophic  centres  and 
the  centres  of  organic  appetite  and  muscular  motion,  is  an 
unmixed  evil  to  the  individual,  and  still  more  so  to  the  race. 
There  is  no  time  nor  place  of  organic  repentance  provided  by 
nature  for  the  sins  of  the  schoolmaster. 

Some  educationalists  go  on  the  theory  that  there  is  an  un- 
limited capacity  in  every  individual  brain  for  education  to 
any  extent  in  any  direction  you  like,  and  that  after  you  have 
strained  the  power  of  the  mental  medium  to  its  utmost,  there 
is  plenty  of  energy  left  for  growth,  nutrition,  and  reproduc- 
tion. ISTothing  is  more  certain  than  that  every  brain  has  at 
starting  just  a  certain  potentiality  of  education  in  any  one 
direction  and  of  power  generally,  and  that  it  is  far  better  not 
to  exhaust  that  potentiality,  and  that  if  too  great  calls  are 
made  in  any  one  direction  it  will  withdraw  energy  from  some 
other  portions  of  the  organ.  These  persons  forget  that  the 
brain,  though  it  has  multiform  functions,  yet  has  a  solidarity 
and  interdependence  through  which  no  portion  of  it  can  be 


580     THE   INSANITIES   OF   PUBERTY   AND   ADOLESCENCE. 

injured  or  exhausted  without  in  some  way  interfering  with 
the  functions  of  the  other  portions.  To  expect  tliat  any  one 
man  could  have  the  biceps  of  a  blacksmith,  the  reasoning 
powers  of  a  Darwin,  the  poetic  feeling  of  a  Tennyson,  the 
procreative  power  of  a  Solomon,  and  the  longevity  of  a  Parr, 
is  simply  to  expect  a  physiological  miracle.  "Man  cannot 
add  a  cubic  to  his  stature."  The  blacksmith's  arm  will  not 
grow  larger  by  twenty  years  of  daily  exercise  after  it  has  once 
attained  a  certain  size.  The  possible  extent  of  development 
of  every  brain  and  of  every  function  in  any  one  brain  is  just 
as  much  confined  by  limitations  as  the  size  of  the  blacksmith's 
arm,  and  physiology  teaches  us  that  no  organ  or  function 
should  be  worked  even  up  to  its  full  limit  of  power.  Ifo 
prudent  engineer  sets  his  safety-valve  just  at  the  point  above 
which  the  boUer  will  burst,  and  no  good  architect  puts  weight 
on  his  beam  just  up  to  the  calculation  above  which  it  will 
break.  ISTature  generally  provides  infinitely  more  reserve 
power  than  the  most  cautious  engineer  or  architect.  She 
scatters  seeds  in  milHons  for  hundreds  to  grow,  and  she  is 
prodigal  of  material  and  strength  in  the  heart  and  aTteries 
beyond  what  is  needed  to  force  the  blood-current  along ; 
therefore  no  function  of  the  brain  should  be  strained  up  to  its 
full  capacity  except  in  extreme  emergencies.  Especially  do 
these  principles  apply  if  we  have  transmitted  weaknesses  in 
any  function  or  part  of  the  organ;  and  what  child  is  born 
in  a  civihsed  country  without  inherited  brain  weaknesses  of 
some  sort  or  in  some  degree? 

These  principles  also  apply,  I  beheve,  most  strongly  to  the 
whole  reproductive  functions  of  the  body  and  its  centres  in 
the  brain,  both  in  the  male  and  the  female.  Especially  are 
they  apphcable  in  the  case  of  the  female  organism,  on  which 
the  chief  strain  of  reproducing  the  species  rests.  The  risks  to 
the  mental  functions  of  the  brain  from  the  exhausting  calls 
of  menstruation,  maternity,  and  lactation,  from  the  nervous 
reflex  influences  of  ovulation,  conception,  and  parturition,  are 
often  enormous   if   there   is  much   original  predisposition  to 


THE   INSANITIES   OF   PUBERTY   AND   ADOLESCENCE.      581 

derangement,  and  the  normally  profound  influences  on  all  tlie 
brain  functions  of  the  great  eras  of  puberty  and  the  climac- 
teric period  are  too  apt,  in  these  circumstances,  to  upset  the 
brain  stability.  Beyond  all  doubt,  boarding-school  education 
has  not  as  yet  been  always  conducted  on  physiological 
principles,  and  is  responsible  for  much  nervous  and  mental 
derangement,  as  well  as  for  difficult  maternity;  but  if  the 
education  of  civilised  young  women  should  become  what  some 
educationalists  would  wish  to  make  it,  all  the  brain  energy 
would  be  used  up  in  cramming  a  knowledge  of  the  sciences, 
and  there  would  be  none  left  at  all  for  trophic  and  repro- 
ductive purposes.  In  fact,  for  the  continuance  of  the  race 
there  would  be  needed  an  incursion  into  lands  where  educa- 
tional theories  were  unknown,  and  where  another  rape  of  the 
Sabines  was  possible.  American  physicians  used  to  tell  us 
that  there  were  some  schools  in  Boston  that  turned  ovit  young 
ladies  so  highly  educated  that  every  particle  of  their  spare  fa't 
was  consumed  by  the  brain-cells  that  subserve  the  functions 
of  cognition  and  memory.  If  these  young  women  did  marry, 
they  seldom  had  more  than  one  or  two  children,  and  only 
puny  creatures  at  that,  whom  they  could  not  nurse,  and  who 
either  died  in  youth  or  grew  up  to  be  feeble-minded  folk. 
Their  mothers  had  not  only  used  up  for  another  purpose 
their  own  reproductive  energy,  but  also  most  of  that  which 
they  should  have  transmitted  to  their  children,  nature,  no 
doubt,  making  provision  for  the  transmission  of  the  unused-up 
energy  of  "one  generation  on  to  the  next,  on  the  principle  of 
the  conservation  of  force.  As  physicians — the  priests  of  the 
body  and  the  guardians  of  the  physical  and  mental  qualities 
of  the  ■  race — we  are,  beyond  all  doubt,  bound  to  oppose 
strenuously  any  and  every  kind  and  mode  of  education  that 
in  any  way  lessens  the  capabihty  of  women  for  healthy 
maternity,  and  the  reproduction  of  future  generations  strong 
mentally  and  physically.  Why  should  we  spoil  a  good  mother 
by  making  an  ordinary  grammarian?  The  relation  of  the 
psychical  and  emotional  development  to  the  generative  function 


582     THE   INSANITIES   OF   PUBERTY   AND   ADOLESCENCE. 

is  full  of  interest  and  importance  to  iis  as  physiologists,  and  few 
men  have  been  long  in  practice  before  such  questions  obtrude 
themselves  as  very  practical  ones  indeed.  The  first  hysterical 
girl  a  man  has  to  treat  in  a  good  family,  where  he  does  not 
want  to  lose  the  case  or  the  family  practice,  may  test  severely 
his  knowledge  of  the  reflex  relationship  of  the  function  of 
reproduction  with  the  sensory,  motor,  and  mental  functions 
of  the  brain.  We  must,  as  much  as  we  can,  study  the  rela- 
tions of  phenomena  of  all  kinds.  It  is  a  mere  cloak  for 
ignorance,  and  an  excuse  for  not  thinking,  to  call  certain 
abnormal  phenomena  "hysterical,"  and  imagine  that  explains 
them.  It  does  not  require  much  consideration  to  see  that  at 
the  period  of  puberty  in  both  sexes,  but  especially  in  the 
female,  the  direct  connection  of  certain  physiological  func- 
tions and  processes  with  certain  mental  facts  influences  the 
whole  life  of  the  individual.  If  that  connection  is  in  any 
way  abnormal,  we  have  great  strains  on  the  mental  functions 
of  the  brain,  and  sometimes  actual  derangement.  Our  high 
civilisation  and  refinement,  no  doubt,  add  to  the  risks  by 
increasing  the  strain.  The  psychological  analysis  of  what 
female  modesty  is,  by  a  physiologist,  reveals  the  transforma- 
tion and  apotheosis  in  the  higher  regions  of  the  brain  of 
reflex  reproductive  impressions  into  a  high  moral  quality, 
not  only  beautiful,  but  absolutely  essential  to  social  life. 
How  can  a  physician  understand  the  true  import  of  the 
obtrusive  and  grotesque  modesty  of  a  hysterical  patient 
except  he  takes  this  into  account?  The  intense  and  com- 
plete outward  repression  and  inhibition  of  certain  physio- 
logical cravings  required  by  our  morals  and  our  civihsation 
causes,  no  doubt,  a  dangerous  strain  on  the  brain  functions, 
and  a  reaction  in  other  directions,  where  there  are  hereditary 
neurotic  weaknesses. 

Puberty  is  the  first  really  dangerous  period  in  the  Kfe  of 
both  sexes  as  regards  the  occurrence  of  insanity  ;  but  it  is  not 
nearly  so  dangerous  as  the  period  of  adolescence,  a  few  years 
afterwards,  when  the  body,  as  well  as  the  functions  of  repro- 


THE   INSANITIES   OF   PUBEKTY  AND   ADOLESCENCE.     583 

duction,  have  more  fully  developed.  There  are  a  few  cases 
of  insanity  in  childhoodj  but  very  few.  They  consist  of 
either  short  attacks  of  delirium  or  short  melanchohc  attacks. 
DeHrium  is  the  typical  psychosis  of  childhood.  Child  melan- 
choly is  a  very  striking  abnormality  when  first  seen,  being  so 
contrary  to  the  normal  mental  state  of  the  period.  I  have 
seen  a  child  of  six  wailing  and  weeping,  with  groundless  fears 
and  suspicions  and  much  obstinacy,  for  two  days.  There  is 
always  a  strong  morbid  heredity  in  such  cases.  The  nutritive 
energy  'of  the  brain  is  so  great  in  youth,  its  recuperative  power 
so  vigorous,  and  its  capacity  for  rest  in  sleep  so  powerful,  that 
its  mental  functions  are  not  often  upset  at  this  period,  and 
when  upset,  they  soon  are  set  right  again.  To  bring  out  this 
fact  statistics  are  useful.  In  Scotland  at  the  present  time 
nearly  one-half  the  population  are  under  the  age  of  20 ;  while 
in  the  Eoyal  Edinburgh  Asylum  we  have,  out  of  a  total  of 
730  patients,  only  ten  under  that  age.  The  contrast  between 
50  per  cent,  and  1*5  per  cent,  in  the  sane  and  insane  popula- 
tions is  a  very  marked  one.  But,  to  show  how  different  is 
the  state  of  matters  in  the  older  periods  of  Hfe,  let  us  com- 
pare the  number  of  persons  over  60  in  Scotland  and  in  the 
Asylum.  In  the  general  population  there  are  just  about  8  per 
cent,  over  that  age,  while  in  the  Asylum,  out  of  the  730,  there 
are  no  less  than  126,  or  17  per  cent.  Or,  to  bring  out  the 
facts  differently,  it  is  found  that  the  number  of  people  so 
insane  as  to  require  to  be  in  asylums  is  about  one  in  600  of 
the  population.  Now,  at  this  rate  our  730  inmates  represent 
an  ordinary  population  of  438,000.  One-half  of  these,  or 
219,000  persons,  are  20  years  of  age  or  under,  and  they  have 
only  supplied  ten  of  our  lunatics,  insanity  occurring  in  them 
at  the  rate  of  only  one  in  21,900,  while  the  remaining  half  of 
the  general  population,  that  over  20,  had  produced  720 
lunatics,  or  one  in  304,  that  is,  in  seventy  times  the  propor- 
tion of  those  under  20  years  of  age.  After  the  age  of  20  there 
is  no  such  enormous  disproportion  at  other  ages  in  the  produc- 
tion of  lunacy.     It  is  undoubtedly  most  frequent  between  the 


584     THE   INSANITIES    OF   PUBERTY   AND   ADOLESCENCE. 

ages  of  35  and  55.  Speaking  generally,  therefore,  insanity  in 
its  -worst  forms  is  not  a  disease  of  youth  or  puberty,  but  of 
middle  and  advanced  life.  Slight  attacks  of  nervous  and 
mental  derangement,  however,  that  do  not  require  asylum 
treatment,  are  by  no  means  uncommon  in  those  predisposed 
to  the  neuroses  at  the  earher  ages,  especially  in  the  female 
sex  ;  and  if  the  general  health  and  strength  and  nutrition  are 
poor,  puberty  is  liable  to  cause  neurotic  symptoms  in  those 
cases.  Such  symptoms,  if  there  is  an  inherited  predisposition 
to  insanity,  should  by  no  means  be  despised.  They  may 
develop  into  actual  insanity  at  a  later  period.  For  the  pro- 
duction of  decided  insanity  requiring  asylum  treatment  at  the 
age  of  puberty  we  must,  as  I  said,  have  a  strong  neurotic  pre- 
disposition, as  well  as  the  advent  of  the  reproductive  era  and 
the  changes  it  brings  along  with  it.  I  have  scarcely  ever  met 
with  a  case  without  this. 

The  Developmental  Neuroses. — Other  affections  of  the 
nervous  centres  are  very  apt  to  appear  at  this  period  of  life, 
notably  the  two  great  derangements  of  the  motor  centres, 
epilepsy  and  chorea.  In  fact,  the  insanities  of  puberty  and 
adolescence  are  merely  two  of  a  great  number  of  develop- 
mental neuroses,  some  of  which  come  on  before  seven  years 
of  age,  during  the  growth  period  of  the  brain,  such  as  convul- 
sions, squint,  stammering,  night  terrors,  infantile  paralysis, 
tubercular  meningitis,  hydrocephalus,  rickets,  and  some 
varieties  of  idiocy  and  imbecihty.  The  next  series  of  this 
group  are  first  met  with  chiefly  in  that  period  when  brain 
growth  is  not  so  acute,  but  when  muscular  motion  becomes 
fully  co-ordinated  with  emotion — the  prepubescent  period — 
that  is,  from  seven  to  fourteen.  The  neuroses  of  this  period 
are  chiefly  chorea,  somnambulism,  asthma,  megrim,  some  eye 
defects,  and  some  amount  of  epilepsy.  The  third  period,  that 
of  puberty  and  adolescence — from  fourteen  to  twenty-five — 
bears  the  neurotic  fruits  of  epilepsy,  hysteria,  adolescent  in- 
sanity, instinctive  immorality,  arrested  body  growth  (dwarfish- 
ness),  ugliness,  joint  disease,  ingrowing  nail,  acne,  and  many 


THE   INSANITIES   OF    PUBEKTY    AND   ADOLESCENCE.     585 

skin  diseases,  many  forms  of  impaired  vision,  barrenness,  and 
perhaps  phthisis  and  acute  rheumatism.^ 

The  Hard  Palate  in  Adolescent  Insanity. — While  investi- 
gating the  physical  characters  of  the  preceding  neuroses  of 
development,  I  discovered  a  curious  line  of  connection  between 
congenital  insanity — idiocy  and  imbecility — and  adolescent 
insanity.  It  had  long  been  known  that  a  high-arched  or 
V-shaped  palate  was  very  common  among  idiots.  I  found 
that  the  palate  might  be  classified  into  three  varieties,  viz., 
the  typical,  the  neurotic,  and  the  deformed  (see  Plates  XI.  and 
XII.).  The  examination  of  large  numbers  of  various  classes 
gave  the  following  results : — 


Frequency  of  the  Three  Types  of  Palate  in  various  Glasses 
of  Persons  examined. 


No.  1. 

No.  2. 

No.  3. 

Number 

The  Diflferent  Classes. 

Typical 

Neurotic 

Deformed 

of  Persons 

Palate. 

Palate. 

Palate. 

examined. 

Per  cent. 

Per  cent. 

The  general  population, 

40-5 

40-5 

19 

604 

Criminals  (the  degenerate),     . 

22 

43 

35 

286 

The  insane  (acquired  insanity), 

23 

44 

33 

761 

Epileptics,     .... 

20 

43 

37 

44 

Adolescent  insanity, 

12 

33 

55 

171 

Idiots  and  imbeciles  (congeni- " 
tal  insanity),      .         .         .  ^ 

11 

28 

61 

169 

Adolescent  insanity  ^  is  thus  seen  to  have  55  per  cent,  of  the 
cases  with  deformed  palate,  thus  approaching  the  61  per  cent, 
among  the  idiots.  No  doubt  the  degree  of  deformity  among 
the  latter  class  was  greater  on  the  average  than  among  the 
former,  but  individual  cases  were  frequent  where  the  degree 
was  quite  as  extreme  in  the  one  as  in  the  other.  The  general 
characters  of  adolescent  deformed  palate  are  seen  in  Plate 
XIII.,  the  figures  of  which  show  vertical  transverse  and  vertical 

^  The  Neuroses  of  Development,  by  the  author. 
2  Op.  cit,,  p.  49. 


586     THE   INSANITIES   OF   PUBERTY   AND   ADOLESCENCE. 

antero-posterior  sections,  taken  from  the  typical  adolescent 
cases  now  in  the  Asylum,  by  Dr  G.  E.  Wilson. 

The  motor  centres  are,  no  doubt,  more  unstable  and  easily 
upset  in  their  working  in  youth  than  either  the  mental, 
sensory,  or  tropliic  centres.  The  insanity  of  puberty,  in  both 
sexes  is  characterised  especially  by  motor  restlessness.  Such 
patients  never  sit  down  by  night  or  day,  and  never  cease 
moving.  There  is  noisy  and  violent  action,  sometimes  irregular 
movements,  or,  in  the  few  melanchohc  forms  and  melancholic 
stages  of  the  maniacal  cases,  cataleptic  rigidity.  The  mental 
symptoms  consist  most  frequently  of  a  kind  of  incoherent 
delirium  rather  than  any  fixed  delusional  state.  In  boys  the 
beginning  of  an  attack  is  frequently  ushered  in  by  a  disturb- 
ance in  the  emotional  condition, — dislikes  to  parents  or 
brothers  or  sisters  expressed  in  a  violent,  open  way ;  there  is 
irrational  dislike  to,  and  avoidance  of,  the  opposite  sex.  The 
manner  of  a  grown-up  man  is  assumed,  and  an  offensive 
"  forwardness  "  of  air  and  demeanour.  This  soon  passes  into 
maniacal  delirium,  which,  however,  is  not  apt  to  last  long.  It 
alternates  with  periods  of  sanity,  and  even  with  short  stages  of 
depression. 

The  following  is  one  of  the  most  characteristic  cases  of  the 
early  insanity  of  puberty  I  have  met  with.  I  have  seen  others 
presenting  the  same  pecuKar  symptoms  : — 

K.  P.,  aet.  11^,  of  an  active  and  cheerful  disposition,  and  a 
bright  boy  at  school.  His  parents  were  poor,  and  he  was 
brought  up  in  a  poor  part  of  the  town.  His  mother  had  an 
attack  of  puerperal  insanity  (mania)  after  the  birth  of  a  child 
born  before  K.  P.,  and  another  attack  of  ordinary  acute 
dehrious  mania  after  he  had  been  sent  to  the  Asylum,  from 
both  of  which  she  recovered,  but  she  died  melancholic.  He 
has  an  elder  brother  who,  at  the  age  of  19,  had  an  attack  of 
adolescent  insanity  (mania),  and  became  demented,  a  sister  has 
since  become  insane,  and  another  sister  was  devoid  of  any  moral 
feeling  or  self-control.  There  was  no  exciting  cause  of  the 
boy's  illness.     He  caught  a  feverish  cold,  and  then  became 


THE   INSANITIES   OF   PUBEETY   AND   ADOLESCENCE.      587 

exalted  in  mind,  singing  continuously,  clinging  to  his  mother, 
saying  he  was  going  to  heaven.  This  continued  aU  day,  hut 
at  night  he  slept  twelve  hours,  and  he  took  his  food  as  usual. 
When  sent  to  .the  Asylum  there  was  a  very  peculiar  mixture 
of  mental  exaltation  and  depression  present.  He  went  on  all 
the  time  singing  joyful  hymns  to  Hvely  tunes,  hut  in  a  voice 
as  if  crying.  He  would  not  answer  questions  nor  take  any 
notice  of  anything  ahout  him,  and  could  not  he  made  to  attend 
to  anything  any  more  than  if  he  had  heen  in  a  condition  of 
trance.  His  whole  condition  was  one  of  almost  mental  autom- 
atism, and  as  he  sang  he  would  rock  himself,  and  keep  time 
rhythmically  with  his  hands  and  hody.  If  any  one  put  their 
arms  round  him  he  would  cuddle  up  to  them,  and  in  a  cliild's 
whining  voice  sing,  "  Tak  me  to  ma  mammy.  Oh  my  honny 
mammy,  my  bonny  mammy ;  come  to  me,  mammy.  Have 
mercy  on  me,"  &c.,  over  and  over  again,  in  a  rhythmical  way  ; 
and  if  his  eyes  were  shut  and  covered  up  he  would  go  right 
off  to  sleep.  The  moment  he  awoke  the  singing  would  begin. 
If  he  were  much  interfered  with  he  would  shout  and  resist 
in  a  sort  of  unconscious  way.  He  was  poorly  nourished  and 
weak  in  body.  He  was  sent  out  in  the  open  air  much,  and 
was  ordered  a  large  quantity  of  mUk  and  cod-liver  oil  emulsion, 
In  about  seven  days  the  state  of  delirium  passed  off,  and  he 
got  quite  well  mentally.  His  father  took  him  home  in  three 
weeks,  but  he  got  into  precisely  the  same  state  again  on  finding 
his  mother  insane  at  home  and  unable  to  speak  to  him.  His 
mother  was  taken  to  the  Asylum,  and  he  took  the  delusion 
that  his  father,  too,  was  dead  and  gone.  In  about  a  fortnight 
he  passed  out  of  the  delirium,  and  became  quite  cheerful  and 
active.  Just  four  weeks  and  two  days  after  his  second  ad- 
mission he  complained  first  of  toothache,  and  then  almost 
immediately  became  very  excited,  and  said  he  could  not  see, 
sobbed,  shouted,  and  was  with  difficulty  restrained  from 
throwing  himself  about.  The  symptoms  were  more  those  of 
ordinary  acute  mania,  but  with  some  of  the  former  delusions, 
automatism,  and  facility  for  sleeping.     This  attack  lasted  for 


588     THE   INSANITIES   OF   PUBERTY   AND   ADOLESCENCE. 

a  few  days  only.  He  then  remained  well  for  exactly  four 
months,  and  then  had  another  attack,  preceded  by  dilatation 
of  the  pupils  and  dimness  of  vision.  The  attack  lasted  for 
three  days.  He  then  got  well  again,  but  in  another  month  to 
a  day  he  got  excited  and  emotional  again.  Though  his  face 
looked  sad,  and  his  voice  was  that  of  weeping,  he  never  shed 
tears.  Tliis  was  the  fifth  attack  he  had;  after  that  he  kept 
well,  was  sent  home,  and  kept  well  for  over  three  years,  when 
he  took  another  attack,  and  now  has  become  demented. 

The  chief  features  of  this  case  were — (1)  the  suddenness 
of  the  coming  on  of  the  mental  attacks,  without  external 
cause ;  (2)  the  curious  automatic  dehrious  character  of  them, 
the  mixture  of  exalted  feeling  with  depression,  and  the 
impossibility  of  rousing  liis  attention  to  anytliing  outside  of 
him ;  (3)  the  way  in  which  he  went  off  to  sleep  when  his 
eyes  were  closed  and  an  arm  was  put  round  him,  in  both 
these  respects  resembling  the  hypnotic  state ;  (4)  the  repeti- 
tion of  the  attacks  in  irregular  monthly  periods ;  (5)  his 
complete  recovery  from  the  first  attack. 

I  look  on  such  a  case  as  an  example  of  the  evolution  of  a 
new  function,  that  of  generation,  upsetting  the  convolutional 
working  of  a  brain  strongly  predisposed  by  heredity  to  in- 
sanity. The  physiological  problem  solving  in  the  brain  at 
this  time  seemed  to  be — Shall  the  organism  have  power  to 
reproduce  itself  1  or  shall  it  die  in  its  highest  function  (men- 
talisation)  in  the  process  of  the  evolution  of  the  power  to 
reproduce  ?  His  elder  brother  had  been  attacked  with 
insanity,  not  at  puberty,  but  during  adolescence,  at  the  age 
of  19.  He  had  at  first  exliibited  a  good  many  cataleptic 
symptoms,  a  motor  automatic  condition,  just  as  K.  P.  had 
many  mental  automatic  symptoms.  In  each  case  the  "higher 
centre  "  of  volition  was  powerless. 

The  treatment  I  look  on  as  an  attempt  so  to  strengthen 
the  vital  forces  and  the  nutrition  of  the  organism  that  it 
shall  pass  safely  through  the  whole  period  of  the  evolution 
of  the  new  function. 


THE   INSANITIES   OF   PUBEKTY   AND   ADOLESCENCE.    589 

K.  P.'s  case  was  no  doubt  in  the  very  earliest  stage  of 
puberty,  and,  indeed,  in  some  of  its  mental  characters 
partook  of  some  of  the  characteristics  of  the  delirium  of 
childhood. 

Adolescence. — The  mental  disturbance  characteristic  of  this 
period  is  closely  allied  to  that  which  occurs  at  puberty.  It 
occurs  later,  between  the  ages  of  18  and  25,  notably  between 
20  and  25,  when  the  function  of  reproduction  is  attaining  its 
full  development  and  the  body  is  arriving  at  its  full  growth. 
That  there  is  such  an  era  in  life  physiologically,  is  sufficiently 
proved  by  the  existence  in  all  languages  of  a  word  to  signify 
the  same  thing  as  our  "  adolescence."  I  cannot  hope  to 
change  the  accepted  meaning  of  the  present  nomenclature, 
but  I  would,  if  I  could,  distinguish  between  puberty  and 
adolescence  in  this  way — I  should  restrict  puberty,  as  is 
now  done  when  the  term  is  used  in  a  scientific  and  phy- 
siological sense,  to  the  initial  development  of  the  function  of 
reproduction,  to  its  first  appearance  as  an  energy  of  the 
organism ;  while  I  should  use  adolescence  to  denote  the 
whole  period  of  twelve  years  from  the  first  appearance  up  to 
the  full  perfection  of  the  reproductive  energy,  when  the 
bones  are  finally  consolidated,  and  the  full  growth  of  the 
beard  and  the  sexual  hair  takes  place,  and  there  occurs  the 
.  perfect  assumption  of  the  manly  form  in  the  male  sex,  and 
the  full  development  of  the  adipose  tissue  and  the  mamma 
gives  the  female  form  its  perfect  grace  of  contour. 

Dr  Matthews  Duncan  has  proved  statistically  that  in  the 
female  sex  "the  climax  of  initial  fecundity,"  which  may  be 
taken  as  proof  of  full  development,  "is  about  the  age  of 
twenty-five  years."  ^  This  may  be  assumed  to  be  the  case 
for  both  sexes. 

Looked  at   from   a   psychological   point   of   view,   it   can 

scarcely   be   denied   by   any   one   that    the   latter   years   of 

adolescence   are  far   more   important   than   the   first.      For 

years  after  puberty,  boys  and  girls  are  still  boys  and  girls  in 

1  Fecundity,  Fertility,  and  Sterility,  2n(i  ed.,  p.  33. 


590      THE  IXSAISTITIES   OF   PUBEKTY   AND   ADOLESCENCE. 

mind,  but  as  a  physiological  fact  the  female  sex  attains  its 
full  bodily  development  first.  At  twenty-one  the  great 
majority  of  that  sex  have  attained  perfect  physiological 
development,  and  Duncan's  statistics  show  that  their  initial 
fecundity  is  then  almost  at  its  climax.  But  this  is  not  so  in 
the  male  sex.  The  growth  of  the  beard  and  the  form  of  the 
body  do  not  reach  full  development  in  that  sex  on  an  average 
till  the  age  of  twenty-five.  Mentally  the  difference  is  still 
more  marked.  The  subtle  but  profound  mental  influences  of 
adolescence  have  usually  reached  their  full  maturity  in  women 
three  or  four  years  before  men.^ 

A  careful  study  of  human  nature  will  soon  show  any 
observer  that  the  period  of  adolescence  in  this  sense  is  a 
most  momentous  one.  The  mental  change  that  takes  place 
from  eighteen  to  twenty-five  is  incomparably  more  important, 
and  I  think  more  interesting  psychologically  too,  than  that 
which  occurs  between  fourteen  and  eighteen.  The  psycho- 
logical change  at  puberty  is,  no  doubt,  great  from  childhood  ; 
but  it  is  inchoate  and  nascent ;  it  wants  precision  and  con- 
scious power ;  its  emotionalism  is  spasmodic  and  childish  ; 
its  sentiment  wants  tenderness,  and  its  ambitions  and  longings 
are  alhed  to  castle-building  in  the  air. 

At  the  latter  period  of  adolescence  in  the  male  sex  life  first 
begins  to  look  serious,  both  from  the  emotional  side  and  in 
action.  It  is  then  only  that  childish  things  are  put  away. 
For  the  first  time  Hterature  in  any  correct  sense  is 
appreciated.  Poetry,  not  even  understood  before,  now  be- 
comes a  passion,  at  least  certain  kinds  of  poetry.  ISTot  that 
the  highest  kind  of  Hterature  is  reached.  'No  adolescent  ever 
really  appreciated,  or  even  thoroughly  liked,  Shakespeare. 
That  is  reserved  for  full  manhood.  The  kind  of  novel  that  is 
enjoyed  is  always  a  good  test  of  the  mental  and  emotional 
development.  The  boy  enjoys  BaUantyne  and  Marryat ;  at 
puberty  the  adolescent   takes   to  Scott  and  Dickens  ;  while 

1  See  Edinburgh  IledicalJourncd,  July  1879,  "The  Study  of  Mental 
Diseases,"  by  the  author. 


THE  INSANITIES  OF  PUBEETY  AND   ADOLESCENCE.   591 

only  the  man  enjoys  and  understands  Shakespeare,  George 
Eliot,  and  Thackeray.  Go  into  a  university  and  watch  the 
demeanour  of  the  first  and  fourth  year's  man,  if  any  one  has 
any  doubt  as  to  the  immeasurable  distance  between  puberty 
and  adolescence.  There  seems  to  be  a  great  gulf  fixed 
between  them.  The  fourth  year's  man  treats  his  junior  not 
as  a  mere  junior,  but  as  of  a  difi'erent  and  inferior  species. 
He  never  speaks  to  him  if  he  can  help  it ;  he  would  no  more 
room  with  him  than  he  would  with  a  baby  in  arms.  Watch 
the  two  in  the  presence  of  the  opposite  sex.  Their  behaviour 
is  quite  difi'erent.  In  the  one  case  you  see  mere  shyness, 
that  breaks  out  into  rolhcking  fun  the  moment  a  real  acquaint- 
ance is  formed ;  in  the  other  there  is  real  sexual  egoism, 
that  most  painful  pleasure  that  consists  of  the  half-conscious 
feeling  that  each  person  of  one  sex  is  an  object  of  the  most 
intense  interest  to  each  person  of  the  opposite  sex  of  the  same 
age.  The  real  events  and  possibilities  of  the  future  are 
reflected  in  vague  and  dreamhke  emotions  and  longings,  that 
have  much  bHss  in  them,  but  not  a  little,  too,  of  seriousness 
and  difficulty.  The  adolescent  feels  instinctively  that  he  has 
now  entered  a  new  country,  the  face  of  which  he  does  not 
know,  but  yet  that  is  full  of  possibility  of  good  and  happiness 
for  him.  He  has  a  craving,  too,  for  action  of  some  sort — 
not  merely  the  football  action  of  the  boy,  but  something  of 
more  serious  import.  Longfellow's  youth,  that  vaguely  cried 
"Excelsior,"  was  evidently  at  this  stage  of  life.  His  reason- 
ing faculty  first  gets  full  back-bone  at  this  period.  His 
emotional  nature  acquires  for  the  first  time  a  leaning  towards 
the  other  sex  that  quite  swallows  up  the  former  emotions. 
It  is  not  yet  at  all  under  his  control,  fixed  or  definite  in  its 
aims.  His  sense  of  the  seriousness  and  responsibility  of  life 
may  be  said  to  awake  then  for  the  first  time  in  a  real  sense. 
The  first  sense  of  right  and  wrong  and  of  duty  becomes  then 
more  active  instead  of  passive.  He  has  yearnings  after  the 
good,  and  is  capable  of  an  intense  hatred  and  scorn  of  evil 
which  he  could  not  have  experienced  before. 


592    THE   INSANITIES   OF   PUBERTY. AND   ADOLESCENCE.  • 

Adolescence  and  its  Characteristics  in  the  Femcde. — But  it  is 
in  the  female  sex  that  the  period  of  adolescence  has  attracted 
most  attention,  especially  among  those  psychological  students 
and  dehneators  of  character,  the  novelists  of  the  day.  As 
physicians,  we  know  that  it  is  only  then  that  hysteria, 
migraine,  and  the  graver  functional  and  reflex  neuroses  arise. 
As  men  of  the  world,  we  know  that  the  love-making,  the 
flirting,  the  engagements  to  marry,  and  the  broken  hearts  of 
the  adolescents  are  not  really  very  serious  affairs.  Tlie  cata- 
clysms of  hfe  do  not  happen  then.  We  know  that  no  artist 
ever  painted,  or  no  sculptor  ever  modelled,  a  Yenus  who  had 
not  reached  adolescence.  A  very  fine  and  most  interesting 
study  of  adolescence  in  the  female  sex  is,  in  my  opinion,  to 
be  found  in  the  Gwendolen  Harleth  of  George  Ehot's  novel 
of  Daniel  Deronda.  This  authoress  was  by  far  the  most 
acute  and  subtle  psychologist  of  her  time,  and  certainly  the 
character  I  have  mentioned  is  most  worthy  of  study  by  all 
physicians  who  look  on  mind  as  being  in  their  field  of  study 
or  sphere  of  action.  From  the  time  when,  at  the  gaming- 
table, Gwendolen  caught  Deronda's  eye,  and  was  totally 
swayed  in  feehng  and  action  by  the  presence  of  a  person  of 
the  other  sex  whom  she  had  never  seen  before ;  playing,  not 
because  she  hked  it  or  wished  to  win,  but  because  he  was 
looking  on,  all  through  the  story  till  her  marriage,  there  is  a 
perfect  picture  of  female  adolescence.  The  subjective  egoism 
tending  towards  objective  duahsm,  the  resolute  action  from 
instinct,  and  the  setting  at  defiance  of  calculation  and  reason, 
the  want  of  any  definite  desire  to  marry,  while  all  her  con- 
duct tended  to  promote  proposals,  the  selfishness  as  regards 
her  relations,  even  her  mother,  and  the  intense  craving  to  be 
admired,  are  all  true  to  nature.  "Witness  her  state  of  mind 
when  Grandcourt  first  appeared  : — 

"  Hence  Gwendolen  had  been  all  ear  to  Lord  Brakenshaw's  mode  of 
accounting  for  Grandcourt's  non-appearance  ;  and  when  he  did  arrive, 
no  consciousness  was  more  awake  to  the  fact  than  hers,  although  she 
steadily  avoided  looking  towards  any  point  where  he  was  likely  to  he. 


THE  INSANITIES   OF   PUBERTY  AND   ADOLESCENCE.     593 

There  should  be  no  slightest  shifting  of  angles  to  betray  that  it  was  of 
any  consequence  to  her  whether  the  much-talked-of  Mr  Mallinger  Grand- 
court  presented  himself  or  not.  And  all  the  while  the  certainty  that  he 
was  there  made  a  distinct  thread  in  her  consciousness." 

Again  : — 

"Gwendolen  knew  certain  differences  in  the  characters  with  which  she 
was  concerned  as  birds  know  climate  and  weather." 

The  sentimentality  of  this  period  of  life  is  well  illustrated 

when  Gwendolen  says  : — 

"  'T  never  saw  a  married  woman  who  had  her  own  way.'  'What 
should  you  like  to  do? '  said  Alex,  quite  guilelessly,  and  in  real  anxiety. 
[He  was  an  adolescent  just  entering  on  the  period.]  '  Oh,  I  don't  know  ! 
Go  to  the  North  Pole,  or  ride  steeplechases,  or  go  to  be  a  queen  in  the 
ball,  like  Lady  Hester  Stanhope,'  said  Gwendolen,  flightily.  'You 
don't  mean  you  would  never  be  married.'  '  No,  I  didn't  say  that.  Only, 
when  I  married,  I  should  not  do  as  other  women  do.' " 

The  inchoate  religious  sentiment,  as  a  psychological  faculty 
contending  with  the  egoism,  is  thus  brought  out : — 

"What  she  unwillingly  recognised,  and  would  liave  been  glad  for 
others  to  be  unaware  of,  was  that  liability  of  hers  to  fits  of  spiritual 
dread.  .  .  .  She  was  ashamed  and  frightened  as  at  what  might  happen 
again,  in  remembering  her  tremor  on  suddenly  finding  herself  alone. 
.  .  .  Solitude  in  any  wide  scene  impressed  her  with  an  undefined  feeling 
of  immeasurable  existence  aloof  from  her,  in  the  midst  of  which  she  was 
helplessly  incapable  of  asserting  herself.  With  human  ears  and  eyes 
about  her  she  had  always  hitherto  recovered  her  confidence,  and  felt  the 
possibility  of  winning  empire." 

The  selfishness  and  craving  for  notice  is  thus  hit  off : — 

"  '  I  like  to  differ  froin  everybody.  I  think  it  is  stupid  to  agree.'  " 
"Her  thoughts  never  dwelt  on  marriage  as  the  fulfilment  of  her 
ambition.  .  .  .  Her  observation  of  matrimony  had  induced  her  to  think 
it  rather  a  dreary  state,  in  which  a  woman  could  not  do  as  she  liked, 
had  more  children  than  were  desirable,  was  consequently  dull,  and 
became  irrevocably  immersed  in  humdrum.  Of  course  marriage  was 
social  promotion.  She  could  not  look  forward  to  a  single  life.  .  .  .  She 
meant  to  do  what  was  pleasant  to  herself  in  a  striking  manner  ;  or 
rather,  whatever  she  could  do  so  as  to  strike  others  with  admiration,  and 
get  in  that  way  a  more  ardent  sense  of  living,  seemed  pleasant  to  her 
fancy." 

But  extracts  merely  spoil  the  whole  picture,  which  is  one 

2  p 


594     THE   INSANITIES   OF   PUBERTY   AND   ADOLESCENCE. 

that  is  in  perfect  accord  with  the  facts  of  nature,  drawn  by  a 
consummate  artist. 

It  seems  Hke  passing  from  the  poetry  of  science  to  Dryas- 
dust's details,  to  descend  from  George  Ehot's  word-pictures  to 
the  details  of  physiological  fact  and  speculation  that  underlie 
all  this  charming  maiden's  mental  constitution.  I  think  most 
medical  men  of  extensive  observation  would  agree  with  me, 
that  the  incompleteness  of  those  mental  tokens  of  merely 
developing  womanhood  and  manhood  during  the  period  of 
adolescence  do  indicate  that  the  conditions  under  which  the 
reproduction  of  the  species  takes  place  should  be  deferred  till 
adolescence  has  passed.  The  love-making  of  adolescence  is 
not  the  serious  matter  it  should  be,  as  Gwendolen's  history 
well  shows ;  and  therefore,  the  full  physiological  and  psycho- 
logical conditions  for  duaUsm  not  being  there,  it  should  not 
be  encouraged.  All  serious  love-making,  engagements  to 
marry,  too  free  intercourse  with  the  other  sex,  too  much 
dancing,  too  much  going  into  society,  merely  tend  to  force 
on  the  full  development,  hke  young  plants  in  a  hothouse, 
with  the  result  that  the  flowers  and  fruit  have  a  tinge  of 
artificialness,  do  not  last,  do  not  stand  the  same  tear  and 
wear.  A  young  man  who  marries  before  his  beard  is  fully 
grown  breaks  a  law  of  nature  and  sins  against  posterity.  A 
girl  who  gets  engaged  while  in  Gwendolen's  state  of  mind  is 
not  likely  to  derive  aU  the  happiness  in  marriage  of  which  she 
is  capable.  It  follows,  therefore,  and  most  members  of  our 
profession  would,  I  think,  agree  with  me,  that  sexual  inter- 
course should  never  be  indulged  in  till  after  adolescence. 

The  period  of  adolescence  is  very  hable  to  those  psycho- 
logical cataclysms  in  weak  brains,  attacks  of  mania,  which 
have  a  special  relationship  to  the  function  of  reproduction. 
Especially  it  seems  to  me  that  the  periodicity  and  remission 
of  the  7iisus  yenerativus  in  both  sexes,  and  the  menstrual 
periodicity  which  accompanies  it  in  women,  are  reflected  in  a 
corresponding  periodicity  and  tendency  to  remission  in  the 
insanity  that  occurs  during  adolescence. 


THE   INSANITIES   OF   PUBERTY   AND   ADOLESCENCE.     595 

Passing  now  from  the  physiological  and  psychological  char- 
acteristics of  adolescence  to  the  forms  of  mental  disease  that 
prevail  then,  the  following  was  a  very  severe  case  of  the 
insanity  of  adolescence  terminating  in  recovery  : — K.  Q.,  set. 
23,  a  student,  who  worked  hard,  who  had  a  neurotic  heredity, 
his  mother  having  had  puerperal  mania  after  the  birth  of 
almost  every  child  and  been  latterly  epileptic,  his  father 
having  been  nervous,  two  sisters  and  one  brother  having 
attacks  of  mania  subsequently  to  his  own  attack.  His  life 
had  been  sedentary,  and  his  bodily  health  and  nutrition  had 
run  down.  He  had  been  given  to  the  habit  of  masturbation. 
He  had  been  working  extra  hard  to  pass  an  examination, 
when  suddenly,  without  any  other  exciting  cause,  he  became 
morbidly  exalted,  lost  his  power  of  sleep,  got  restless,  talka- 
tive, violent,  and  unmanageable  at  home.  Within  four  days 
he  had  to  be  sent  to  the  Asylum.  He  then  laboured  under 
acute,  almost  delirious,  mania.  He  was  exalted,  giving  inco- 
herent descriptions  of  metaphysical  speculations  and  mental 
problems.  There  was  a  great  deal  of  the  sexual  element 
running  through  his  incoherence  and  his  speculations.  His 
temperature  was  100'1° ;  his  pulse  84,  weak  ;  his  weight  11  st. 
12  lbs.  He  was  kept  outside  nearly  all  day  in  charge  of  two 
good  attendants,  though  most  violent ;  he  was  compelled  to 
take  four  custards  a  day,  each  containing  four  eggs  and  a  pint 
and  a  half  of  milk,  in  addition  to  any  ordinary  food  he  could 
be  got  to  take.  He  was  treated  with  warm  baths  at  night, 
with  cold  to  his  head,  and  large  doses  of  bromide  and  iodide 
of  potassium  combined  while  the  temperature  was  high.  He 
slept  little,  and  in  spite  of  the  enormous  quantity  of  nourish- 
ment taken  he  fell  off  in  flesh  and  strength.  Contrary  to 
my  usual  custom  in  adolescent  cases,  I  added  a  considerable 
quantity  of  port  wine  to  his  diet,  as  he  looked  at  times  so 
exhausted.  In  the  first  six  weeks  of  his  stay  in  the  Asylum 
he  lost  28  lbs.  in  weight.  All  kinds  of  sedatives  were  tried 
temporarily  in  vain.  I  thought  he  was  going  to  die  of  ex- 
haustion.    He  had  a  slight  beginning  of  a  haematoma,  which 


596     THE   INSANITIES   OF   PUBERTY   AND   ADOLESCENCE. 

was  blistered,  and  so  stopped.  The  excitement  became  paroxys- 
mal and  recurrent  in  its  intensity,  though  he  Avas  never  free 
from  it.  After  about  two  months  the  intensity  of  the  mania- 
cal condition  began  to  abate,  and  he  passed  into  what  is  to  me 
a  most  anxious  stage  in  these  cases.  His  expression  of  face 
became  enfeebled  looking,  liis  habits  dirty,  he  masturbated 
badly,  and  his  whole  mental  state  suggested  secondary 
dementia  rather  than  either  mania  or  recovery.  One  cannot 
pay  ■  sufficient  attention  to  the  treatment  of  such  symptoms 
in  that  stage.  The  nourishment  was  made  a  little  more 
stimulating  by  strong  soups,  in  addition  to  the  milk  and  eggs. 
He  got  fresh  vegetables,  cod-liver  oil  with  the  hypophosphites, 
and  strychnine  and  iron.  He  was  narroAvly  watched  and 
well  nursed,  and  much  moral  treatment  adopted  to  rouse 
and  interest  him.  It  seemed  to  be  in  truth  a  toss-up  between 
recovery  and  dementia,  between  mental  life  and  mental  death. 
Fortunately  the  recuperative  power  of  his  brain  and  constitu- 
tion prevailed,  he  slowly  picked  up  flesh,  and  his  beard  and 
whiskers  began  to  sprout, — I  have  much  faith  in  adolescent 
recoveries  when  the  beard  grows  coincidently  with  recovery, 
— and  his  weight  increased  fast  and  steadily,  until  in  six 
months  from  the  commencement  of  his  illness  he  was  quite 
well  in  mind,  and  strong  and  stout  in  body,  weighing  13  st. 
His  was  one  of  only  about  ten  patients  that  I  have  seen  where 
even  partial  recovery  took  place  after  a  hsematoma  had  formed, 
or  even  been  threatened  in  any  degree.  Unfortunately,  after 
living  in  the  country  for  a  time  he  came  back  to  a  city  life, 
could  not  get  work,  had  domestic  trials,  and  became  insane 
again  in  eighteen  months — this  time  the  symptoms  being 
melanchohc ;  but  from  this  he  also  recovered,  kept  well  for 
a  time,  then  had  another  attack  of  mania,  which  ended  in 
secondary  dementia. 

Lives  that  looked  full  of  promise  are  sometimes  blasted  on 
the  threshold  of  what  seem  most  brilliant  careers,  as  in  the 
following  case  of  K.  E.,  aet.  20.  Heredity  very  neurotic, 
mother  being  very  nervous,  aunt  insane,  and  father  drunken. 


THE   INSANITIES   OF   PUBERTY   AND   ADOLESCENCE.     597 

He  had  been  a  most  brilliant  and  successful  student,  and  lie 
bad  poetic  gifts  that  made  his  friends  look  forward  to  his 
future*  with  much  enthusiasm.  His  illness  came  on  when  he 
was  reading  hard,  sleeping  little,  supporting  himself  by  teach- 
ing, and  also  perhaps  further  exhausting  his  energy  by  illicit 
sexual  indulgence.  Without  any  proximate  cause  he  became 
much  exalted  in  mind  and  much  excited,  sleepless,  and  fell  off 
his  food.  The  common  remedy  of  enormous  doses  of  morphia 
was  resorted  to,  which  caused  sleep,  but  he  was  no  better  for 
it,  and  after  it  would  take  no  food  whatever.  When  he  came 
to  the  Asylum  he  was  quite  incoherent,  raving  about  religion 
and  women.  His  tongue  and  lips  were  dry ;  his  temperature 
99°;  pulse  144,  small  and  thready;  and  his  general  strength 
small,  though  his  maniacal  muscular  energy  was  great.  I 
could  get  him  to  take  no  food,  so  at  once  fed  him  with  the 
stomach-pump.  He  had  to  be  put  in  the  padded  room  at 
night  on  account  of  his  delirious  violence,  but  was  taken  out 
each  day  into  the  fresh  air  by  three  good  attendants.  He 
began  to  take  his  food  after  a  few  days,  but  remained  acutely 
excited  for  a  fortnight.  Then  there  was  a  remission,  but  the 
mania  came  on  again,  as  indeed  it  did  all  through  his  case,  by 
spurts.  In  about  three  months  he  began  to  be  more  coherent, 
and  wrote  some  poetry.  As  it  illustrates  the  common  mixture 
of  religious  and  sexual  emotion  in  this  and  most  of  those  cases 
very  graphically,  I  quote  some  of  it  here  : — 

A  SOLEMN  ANTHEM  IN  CELEBRATION  OF  THE 
NEW  JERUSALEM. 

O,  Rosaly,  ray  warm  and  panting  girl, 
Just  image  to  yourself  the  gates  of  pearl  ! 
The  angels  sitting  in  illustrious  row, 
Kissing  their  hands  to  the  Holy  Ghost  below 
That  glorious  unimagined  mystery, 
Tlie  very  hot  and  lovely  Trinity, 
Afar  they  see  the  late  of  crystal  shine, 
Filled  with  the  juice  of  maidens'  paps  divine 
They  hear  the  sappy  sound  of  neighbouring  love 
And  kisses,  sacred  as  the  brooding  dove. 


598     THE   INSANITIES   OF   PUBERTY   AND   ADOLESCENCE. 

They  look  unto  the  Great  "White  Throne  and  laugh. 

Christ  plies  the  Virgin  with  luxurious  chatf ; 

Jehovah  feels  the  Queen  of  Sheba's  beauty. 

And  refers  to  the  loveliness  of  Duty. 

The  Devil  reads  the  Sermon  on  the  Mount, 

And  adds  a  little  on  his  own  account. 

And  so  they  sing  their  wicked  songs  together, 

While  God  in  anger  frowns  upon  the  weather. 

His  bodily  health  and  strength  gradually  improved,  his 
beard  and  whiskers  sprouted  in  great  luxuriance,  but  his 
mental  power  did  not  return.  He  continued  to  write  poetry, 
but  it  got  more  and  more  incoherent.  He  called  himself  at 
times  "Jesas  Christ,  Prince  Algernon  Swinburne,"  though 
this  was  scarcely  a  fixed  delusion.  He  had  been  an  intense 
admirer  and  great  reader  of  Swinburne's  poems,  and,  as  in 
the  specimen  given  above,  all  his  insane  poems  were  intiuenced 
by  the  rhythm  and  perhaps  by  the  early  ideas  of  that  poet. 
The  treatment  adopted  was  the  same  as  in  the  previous 
case,  but  to  no  avail  as  regards  his  recovery.  The  change  to 
another  asylum  was  tried,  but  did  not  rouse  him.  He  sunk 
into  dementia  in  about  two  years. 

The  following  patient  was  not  a  head  worker : — K.  S.,  set. 
21.  A  quiet,  steady,  and  intelligent  fisherman;  stout,  ruddy, 
and  strong  in  body.  He  came  of  one  of  the  famiUes  of  the 
fishing  village  of  Newhaven  that  must  have  had  some  very 
unstable  mental  stock  introduced  into  them  many  genera- 
tions since,  and  that  have  intermarried  for  many  years,  and 
in  many  of  which  now  there  is  an  enormous  amount  of  in- 
sanity or  epilepsy.  I  know  one  such  family  of  which  twelve 
members  out  of  four  generations  have  been  in  the  Asylum, 
brothers  and  sisters  and  cousins,  some  of  them  maniacal,  some 
melancholic,  some  epileptic,  some  idiotic,  and  many  of  them 
dying  of  phthisis.  In  four-fifths  of  them  those  neuroses 
appeared  first  during  adolescence,  this  being  most  marked  in 
the  younger  generations.  If  any  proof  were  needed  of  the 
supreme  importance  of  hereditary  influences  in  the  production 
of  mental  diseases  and  epilepsy,  and  the  small  influence  of 


THE   INSANITIES   OF   PUBERTY  AND   ADOLESCENCE.    599 

healthy  conditions  of  hf e  in  counteracting  these  hereditary- 
influences  in  many  instances,  I  would  point  to  the  village  of 
NewhaVen.     The  people  are  well-fed  fisher  folks.     They  are 
robust  and  handsome.     Most  of  the  "  bonny  fishwives  "  that 
are  so  picturesque  an  element  in  the  street  scenes  and  street 
sounds  of  Edinburgh  belong  to  this  village.     The  life  they 
lead  is  a  natural  outdoor  one,  and  yet  insanity  is  more  common 
among  them  than  in  any  community  of  a  similar  size  I  know. 
That  fact,  along  with   others,  notoriously  the  frequency  of 
insanity  among  the  old  famihes  of   the  Society  of   Friends, 
the  most  self-controlled  and  virtuous  of  all  religious  sects,  is 
a  complete  answer  to  those  who  say  that  mental  diseases  are 
mostly  due  to  drink  and  vice  and  the  manifestly  bad  and 
unnatural  conditions  of  modern  town  life.     But  to  return  to 
K,  S.     He  at  first  behaved  as  if  something  was  "preying  on 
his  mind,"  and  when  questioned  could  only  assign  as  a  cause 
a  common  dispute  in  a  boat.     This  was  no  doubt  the  melan- 
cholic prelude  to  the  attack.     Then  he  became  elevated,  and 
then  maniacal  and  violent.     This  lasted  for   about  a  week, 
and  then  he  appeared  to  get  well.     In  a  few  weeks  he  again 
became  maniacal,  and  was  sent  to  the  Asylum.     His  bodily 
health  seemed  absolutely  perfect  in  all  respects.     He  was  a 
fine,  fresh,  ruddy  young  son  of  the  sea.     He  was  set  to  hard 
work  in  the  garden,  and  in  ten  days  became  rational  and  quiet, 
and  kept   well  for  three  years.     I  noticed  that  during  the 
three  months  he  was  in  the  Asylum  his  beard  and  whiskers, 
which  were  nascent  on  admission,  grew  out  full  and  strong, 
so  that,  though  he  came  in  smooth-faced,  he  left  a  bearded 
man.     He  had  a  subsequent  attack  of  a  similar  kind  in  three 
years,  from  which  he  also  recovered,  and  the  last  I  saw  of 
him  was  when  he  came  to  tell  me  he  was  going  to  get  married. 
No  doubt  he  will  have  a  numerous  neurotic  and  insane  pro- 
geny, for  he  looked  in  glorious  bodily  health  and  vigour. 
This  was  a  case  in  which  there  seemed  absolutely  no  exciting 
cause  whatever  for  the  attack   but  the  completion  of   the 
period  of  adolescence. 


600    THE   INSANITIES   OF   PUBERTY   AND   ADOLESCENCE. 

The  last  case  I  shall  refer  to  is  one  where  recovery  did  not 
take  place,  but  dementia  resulted.  K.  Y,,  set.  16.  Has  an 
aunt  a  patient  in  the  Asylum.  Had  been  a  month  ill  before 
admission.  He  was  excited,  noisy,  shouting,  and  dancing 
about.  That  was  in  1878.  For  four  years  he  ^vsis  subject  to 
attacks  of  acute  maniacal  excitement  at  intervals  of  a  few 
months.  In  the  first  year  they  were  very  acute.  This  is  a 
general  rule.  My  experience  is  that  the  first  attack  or  the 
second  is  apt  to  be  the  worst.  In  K.  V.'s  case  the  attacks 
got  less  acute  after  the  first  year,  but  in  the  intervals  between 
the  attacks  he  was  less  sane.  A  clouding  process  over  his 
mind  went  on,  each  attack  leaving  him  rather  more  enfeebled 
than  the  last.  But  he  was  once  so  well  that  he  was  tried  at 
home  for  a  short  time.  He  gradually  sank  into  secondary 
dementia,  with  rare  and  occasional  spurts  of  restlessness  and 
mild  maniacal  excitement  at  irregular  intervals  —  a  type 
of  the  healthy  chronic  lunatic  that  forms  half  the  population 
of  most  asylums,  and  he  is  likely  to  live  for  many  years. 
He  can  work  in  the  garden,  can  answer  simple  questions, 
sleeps  weU,  is  not  uncleanly  in  his  habits,  mingles  in  the 
Asylum  amusements,  but  all  his  "higher  nature"  is  gone. 
He  cares  Kttle  for  his  relations.  His  joys  and  sorrows  are 
very  mild.  He  has  no  interest  in  hfe,  no  ambition,  no  great' 
sense  of  right  or  wrong,  no  vohtion  in  any  higher  sense,  and 
no  religious  instinct. 

Treatment  of  the  Insanity  of  Adolescence. — The  treatment 
I  have  lately  adopted  for  such  cases  is  founded  on  physio- 
logical considerations.  The  normal. completion  of  the  period 
of  adolescence  is  in  both  sexes  accompanied  by  a  consider- 
able deposit  of  adipose  tissue,  by  an  overplus  of  strength  and 
activity,  and  by  a  state  of  general  good  nourishment  of  the 
body.  To  attain  to  this  normal  condition  of  body  should 
undoubtedly  be  our  aim  in  treating  all  cases  of  mental  disease 
at  this  period.  It  always  seemed  to  me  that  there  were  two 
things  that  constantly  worked  the  other  way,  and  that  I 
had  to  contend  against  in  their  treatment.     These  Avere  the 


THE   INSANITIES   OF  PUBERTY  AND   ADOLESCENCE.    601 

general  brain  excitability,  and  the  morbid  strength,  and  often 
perversion,  of  the  generative  nisus  with  the  inhibitory  power 
over  it  gone.  The  one  tended  to  mania,  sleeplessness,  purpose- 
less motor  action,  thinness,  and  exhaustion ;  the  other  to 
erotic  trains  of  thought,  sexual  excitement,  and  masturbation. 
I  found  that  inaction,  reading,  indoor  life  and  amusements 
increased  the  one,  while  novel-reading,  solitariness,  and  long 
hours  in  bed  aggravated  the  other,  while  animal  food  and 
alcoholic  stimulants  gave  increased  strength  to  both  morbid 
tendencies.  I  therefore  put  my  patients  to  active  exercise 
in  the  open  air  for  as  many  hours  a  day  as  possible,  walking, 
digging  in  the  garden,  wheehng  barrows ;  I  give  them  shower 
baths  in  the  morning  when  the  weather  is  suitable  and  they 
are  strong  enough,  and  I  encourage  active  muscular  exercise 
in  every  way.  Athletic  games  of  all  sorts  in  the  open  air  are 
certainly  good  so  far  as  they  go.  I  place  great  reliance  on 
the  diet.  Milk  in  large  quantity,  and  as  often  in  the  day  as 
possible,  bread,  porridge,  and  broth  are  the  staple  articles  of 
food  for  such  patients  here.  My  friend  Dr  Keith,  of  this 
city,  was  the  first  to  direct  my  attention  to  the  advantage  of 
a  light  farinaceous  and  milk  diet  in  another  class  of  cases,  and 
my  experience  is  strongly  in  favour  of  his  views.  The  patients 
may  have  some  fish,  or  fowl,  or  eggs,  but  in  reality  milk  is 
the  most  important  means  of  treatment.  I  seldom  give  such 
cases  alcoholic  stimulants.  I  give  to  all  such  patients  who 
can  take  and  assimilate  it  easily  an  emulsion  of  cod-liver  oil, 
hypophosphite  of  lime,  and  pepsine,  made  and  flavoured  in 
such  a  way  that  it  resembles  cream  or  extract  of  malt.  I  find 
very  few  indeed  who  cannot  take  this.  Beyond  this,  an 
occasional  bitter  tonic,  with  sometimes  a  chalybeate  or  some 
of  the  new  compound  syrups  of  the  phosphates,  are  about  all 
the  medicines  I  give.  The  effect  of  this  diet,  regimen,  and 
treatment  is  very  marked  in  the  majority  of  cases.  ]^o  doubt 
during  the  first  part  of  the  attack  patients  may  lose  weight 
while  the  excitement  is  in  its  most  acute  stage ;  but  they  soon 
begin  to  gain  weight,  and  my  prognosis  is  always  favourable 


602    THE   INSANITIES   OF   PUBERTY   AND   ADOLESCENCE. 

when  I  find  a  patient  beginning  to  gain  weight  within  a 
reasonable  time,  say  six  months  or  so.  I  have  had  patients 
who,  in  spite  of  very  sharp  excitement  indeed  and  much 
sleeplessness,  gained  weight  under  this  treatment.  It  seems 
to  me  that  the  process  of  fattening  such  a  patient,  and  the 
conditions  under  wliich  it  takes  place,  are  antagonistic  to  the 
disease  and  its  results.  I  have  known  the  stopping  of  the 
cod-liver  oil  to  be  followed  at  once  by  a  loss  or  diminished 
gain  in  weight,  and  its  resumption  to  be  followed  by  the 
former  rate  of  increase.  If  a  young  man  or  woman  suffering 
under  the  insanity  of  adolescence  is  found  to  gain  one  or  two 
pounds  a  week  within  the  first  three  months,  I  look  on  him 
as  quite  safe.     It  is  common  to  gain  a  stone  in  a  month. 

I  have  now  pursued  this  plan  of  treatment  long  enough  to 
yield  results  that  can  be  relied  on,  and  I  beheve  that  more  of 
my  patients  recover  than  before  I  adopted  it.  They  recover 
sooner,  and  their  recoveries  are  more  rehable  and  permanent. 
Even  in  the  case  of  those  who  sink  into  dementia,  I  think 
they  do  so  more  quietly  and  with  less  of  the  element  of 
chronic  mania  than  under  a  flesh  diet.  It  is,  I  think,  certain 
that  the  habit  of  masturbation,  which  is  so  frequent  and  so 
deleterious  in  such  cases,  is  less  practised  by  patients  on  this 
diet,  and,  when  practised,  is  less  damaging  to  brain  function, 
and  takes  less  hold  on  them. 

Lastly,  in  connection  with  this  subject,  I  would  say  a  word 
about  prophylaxis  in  cliildren  with  a  strong  neurotic  inherit- 
ance. My  experience  is  that  the  children  who  have  the  most 
neurotic  temperament  and  diathesis,  and  who  show  the 
greatest  tendencies  to  instabihty  of  brain,  are  as  a  rule  flesh- 
eaters,  having  a  craving  for  animal  food  too  often  and  in  too 
great  quantities.  I  have  found  also  a  large  proportion  of 
the  adolescent  insane  had  been  flesh-eaters,  consuming  and 
having  a  craving  for  much  animal  food.  It  is  in  such  boys 
that  the  habit  of  masturbation  is  most  apt  to  be  acquired, 
and,  when  acquired,  produces  such  a  fascination  and  a  crav- 
ing that  it  may  ruin  the  bodily  and  mental  powers.     I  have 


THE   INSANITIES   OF    PUBERTY   AND   ADOLESCENCE.     603 

seen  a  change  of  diet  to  milk,  fish,  and  farinaceous  food 
produce  a  marked  improvement  in  regard  to  the  nervous 
irritab'iHty  of  such  children.  And  in  such  children  I 
thoroughly  agree  with  Dr  Keith,  who  in  Edinburgh  for 
many  years  has  preached  an  anti-flesh  crusade  in  the  bringing 
up  of  children  up  to  eight  or  ten  years  of  age.  I  believe  that 
by  a  proper  diet  and  regimen,  more  than  in  any  other  way, 
we  can  fight  against  and  counteract  inherited  neurotic  ten- 
dencies in  children,  and  tide  them  safely  over  the  periods  of 
puberty  and  adolescence. 

Statistics. — The  following  is  a  statistical  and  clinical  inquiry 
into  the  subject  of  the  insanity  of  adolescence.  For  this 
inquiry  I  took  for  the  period  of  five  years  and  a  quarter 
(from  1874  till  the  end  of  the  first  quarter  of  1879)  all  the 
cases  that  were  admitted  into  the  Eoyal  Edinburgh  Asylum. 
They  amounted  to  1796  —  917  men  and  879  women.  Of 
these,  320  were  between  the  ages  of  14  and  25,  viz.,  195 
males  and  125  females.  ISTow,  if  my  object  had  merely 
been  to  arrange  those  320  patients  each  in  a  classification  of 
symptoms,  it  would  have  been  simple  enough :  so  many 
with  exaltation  under  "Mania,"  so  many  with  depression 
under  "Melanchoha,"  &c.  That  was  done,  but  a  great  deal 
more  information  must  be  expiscated  about  each  case  if 
we  are  to  arrange  them  in  chnical  or  physiological  groups, 
and  especially  if  we  are  to  have  any  light  thrown  on  the 
question — "Did  adolescence  influence  the  mental  symptoms 
present  in  those  cases  1 "  "We  must  ask  and  answer  the 
following  inquiries: — "In  how  many  cases  did  the  disease 
exist  before  the  age  of  14,  or  was  of  a  kind  with  which 
adolescence  could  have  notliing  to  do  ? "  I  found  I  had  to 
deduct  90  such  cases,  or  about  one-third  of  the  320,  those 
having  been  mentally  defective  or  epileptic  from  birth,  or  at 
very  early  ages,  or  laboured  under  organic  disease,  or  in 
whom  the  disease  came  on  in  nursing  or  cliildbirth,  leaving 
230  in  whom  it  was  possible  for  puberty  or  adolescence  to 
cause  or  influence  the  disease. 


604     THE   INSANITIES   OF   PUBERTY  AND   ADOLESCENCE. 

The  next  inquiry  naturally  was — "If  230  occurred  in  the 
twelve  years  between  the  ages  of  14  and  25,  is  that  proportion 
greater  or  less  than  is  found  in  the  same  number  of  years  at 
other  ages?  I  find  it  to  be  far  more  than  between  2  and  14, 
but  less  (10  per  cent.)  than  between  30  and  40.  At  this  par- 
ticular age,  either  from  adolescence  or  some  other  cause,  it  is 
clear  that  there  arises  a  liability  to  insanity  which  did  not 
before  exist,  but  which  does  not  cease  when  adolescence  is 
past. 

The  next  query  was  tliis  : — "  Taking  this  long  period  of 
twelve  years,  is  there  any  special  hability  during  any  of  the 
years  of  that  time  ?"  "Does  it  arise  at  puberty,  or  towards 
the  completion  of  the  period  of  adolescence  ? "  A  glance  at 
the  numbers  who  became  insane  in  each  of  the  twelve  years 
shows  that  the  first  two,  that  is  the  14th  and  15th,  were 
especially  exempt,  only  producing  one  case  each ;  and  the 
next  two,  the  16th  and  17th,  also  very  few  (22).  ISTow,  the 
fact  that  there  only  occurred  in  those  four  years  of  hfe  24 
cases  out  of  about  1800  in  a.ll  (230  of  them  being  adolescents 
and  healthy  up  to  that  period),  does  show  clearly  that  the 
first  onset  of  the  reproductive  function  is  not  a  dangerous  one 
as  regards  liability  to  insanity,  however  Hable  it  may  be  to 
chorea,  epilepsy,  and  other  neuroses  of  development. 

The  next  three  years — the  18th,  19th,  and  20th — were 
still  low,  producing  only  49  cases,  or  an  average  of  16  in 
each  year.  In  those  three  years,  while  puberty  has  occurred 
in  nearly  every  individual  of  both  sexes,  yet  adolescence  has 
been  completed  in  very  few  of  them. 

It  was  in  the  next  five  years,  from  the  21st  to  the  25th, 
that  the  vast  majority  of  the  cases  occurred,  viz.,  157  of  the 
230,  or  an  average  of  31  in  each  year  as  compared  with  an 
average  of  8  for  each  of  the  first  five  years.  At  14  and  15  the 
liabihty  to  insanity  was  practically  nil,  from  21  to  25  it  was 
very  great.  In  fact,  a  comparison  with  the  habihty  at  other 
ages  during  the  past  five  years  in  the  admissions  to  the 
Asylum  shows  that  there  is  no  period  of  life  where  uncom- 


THE   INSANITIES   OF    PUBERTY  AND   ADOLESCENCE.     605 

plicated  insanity  occurs  more  frequently  than  during  the 
completion  of  the  physiological  era  of  adolescence,  from  21 
to '25 '(see  Plate  Y.).  It  must  be  kept  in  mind  that  I  am 
not  now  speaking  of  the  numbers  becoming  insane  in  pro- 
portion to  the  number  of  the  general  population  alive  at 
any  particular  period.  Those  statistics  are  confirmed  in  the 
main  by  those  of  Lewis. ^ 

Comparing  the  two  sexes,  the  total  numbers  and  relative 
proportion  of  females  are  smaller  in  the  adolescent  period 
than  at  later  periods  of  life.  Adolescence  does  not  appear  to 
be  so  powerful  an  upsetter  of  mental  equilibrium  in  women  as 
in  men. 

Symptoms. — Having  elucidated  those  points,  we  come  to 
the  question  as  to  what  mental  symptoms  these  adolescents 
suffered  from,  and  if  those  symptoms  were  in  any  way 
peculiar?  While  investigating  this,  I  found  the  complica- 
tions of  marriage,  child-bearing,  and  lactation  in  the  females 
so  common  after  the  age  of  21,  that  it  was  difficult  to  com- 
pare them  with  the  males.  I  therefore  made  21  the  limit 
of  age  for  them.  This  reduced  their  numbers  to  40,  making, 
with  the  140  males,  180. 

The  first  fact  of  importance  is,  that  there  were  only  40 
cases  where  the  symptoms  present  were  classed  as  states  of 
mental  depression  or  melancholia,  while  the  rest  Avere  cases 
of  exaltation  or  mania.  Now,  the  significance  of  this  pro- 
portion is  only  seen  by  comparison.  During  the  past  five 
years  in  the  Asylum  there  have  been  admitted  nearly  two 
cases  of  uncomplicated  mania  to  one  of  melancholia  (849  to 
439),  whereas  among  the  adolescents  it  was  3|-  to  1  (140  to 
40).  And  if  we  compare  them  with  those  at  more  advanced 
ages,  e.g.,  women  at  the  climacteric  period,  the  proportion  of 
mania  to  melancholia  is  then  reversed,  there  being  one  case 
of  the  former  to  If  of  the  latter. 

The  proportion  of  states  of  exaltation  of  mind  or  mania, 
therefore,  is  much  greater  as  compared  with  those  of  melan- 
^  Text-Book  of  Mental  Diseases,  by  W.  Bevan  Lewis,  p.  334. 


606    THE   INSANITIES   OF   PUBERTY   AND   ADOLESCENCE. 

cliolia  among  the  adolescent  insane  than  among  the  insane  at 
all  ages,  tliis  excess  being  still  more  marked  "when  compared 
with  the  cases  of  mental  disease  occurring  at  the  climacteric 
period  of  life. 

Relapsing  Mania. — The  next  inquiry  was — "  What  was 
the  character  of  the  mania?"  I  found  it  had  several  well- 
marked  characteristics.  It  was,  in  the  first  place,  often  of  a 
very  acute,  though  seldom  of  a  delirious  type ;  in  the  second 
place,  it  was  mostly  of  short  duration,  the  patients  getting 
soon  apparently  quite  well;  in  the  third  place,  the  patients 
were  subject  to  constant  relapses.  Out  of  the  180  cases,  118, 
or  66  per  cent.,  had  such  intermissions  of  sanity  with  sub- 
sequent relapses.  This  tendency  to  short  sharp  attacks, 
with  intermissions  of  more  perfect  sanity  than  occur  in  most 
other  kinds  of  mental  disease,  with  relapses  occurring  one, 
two,  three,  four,  and  five  times,  and  even  more  frequently, 
before  recovery  or  dementia  finally  takes  place,  may  be  taken 
to  be  especially  characteristic  of  this  insanity  of  adolescence. 
In  many  of  them,  as  the  maniacal  attacks  passed  ofi",  there 
was  a  sHght  tendency  to  melancholia.  This  was  noticed  in  62 
cases.  In  a  few  cases  headaches  came  on  and  evidently  took 
the  place  of  the  psychosis.  This  relapsing  character,  with  the 
tendency  towards  depression,  brings  adolescent  insanity  into 
relationship  with  folic  circulaire.  The  real  cause  of  the 
remissional  character  of  both  is  no  doubt  the  periodicity 
of  the  generative  power  and  desire. 

Another  well-marked  characteristic  was  this,  that  a  here- 
ditary predisposition  to  mental  disease,  or  at  least  to  some  of 
the  graver  neuroses,  was  present  in  77  of  the  180,  or  in  45  per 
cent,  of  the  whole  number.  But  subsequent  investigations  gave 
65  per  cent,  of  such  heredity  in  the  adolescent  insane.  It  is  very 
difficult  to  get  family  histories  of  insanity  in  most  cases,  and 
you  may  often  multiply  by  two  those  you  get,  if  you  want  an 
approach  to  the  truth,  at  all  events  if  you  take  in  the  graver 
neuroses.  Our  proportion  of  hereditary  predisposition  in  the 
Asylum,  as  recorded  in  our  Case-Books,  is  only  23  per  cent.. 


THE   INSANITIES   OF   PUBERTY   AND   ADOLESCENCE.     607 

as  compared  with  the  45  per  cent,  among  the  adolescents,  in 
whose  cases  no  special  pains  had  been  taken  to  ascertain 
family,  histories.  I  observed  a  still  more  striking  fact  in 
regard  to  the  heredity  of  the  insanity  of  adolescents.  I 
happened  to  have  a  personal  knowledge  of  the  history  of  the 
cases  or  of  the  families  in  fifteen  of  the  cases,  and  in  twelve 
of  these  there  was  a  hereditary  predisposition  to  the  neuroses. 
It  is  a  common  enough  fact  to  have  the  children  of  a  neurotic 
couple,  one  or  both  being  highly  intellectual,  sensitive,  artistic, 
and  rehgious,  but  wanting  in  stability,  or  common  sense,  or 
self-control,  yet,  with  no  insanity  nor  epilepsy — it  is  common 
to  find  one  or  more  of  the  children  of  such  a  couple  subject  to 
adolescent  insanity,  instinctive  immorality  or  hysteria.  The 
insanity  of  adolescence  is  therefore  predisposed  to,  in  most 
cases  by  a  nervous  heredity,  being  in  fact  the  most  hereditary 
of  all  forms  of  mental  disease. 

Another  marked  character  of  the  mania  was  that  the 
ideas,  emotions,  speech,  and  conduct  were  all  strongly  tinctured 
by  the  normal  mental  characteristics  of  adolescence  in  an 
exaggerated  or  morbid  way.  That  perversion  of  the  sexual 
act,  the  habit  of  masturbation,  was  very  common,  probably 
existing  in  over  50  per  cent,  of  the  cases,  aggravating  the 
symptoms  and  diminishing  the  chances  of  recovery.  In  the 
females  hysterical  symptoms  were  common,  such  as  mock 
modesty,  simulated  pains,  and  a  desire  to  attract  attention. 
In  the  males  heroic  notions,  an  imitation  of  manly  airs 
and  manners,  an  obtrusive  pugnaciousness,  and  sometimes 
a  morbid  sentimentality  were  present.  In  almost  all  the 
cases  the  physical  appearance  of  the  males  was  boyish  when 
the  attack  commenced ;  and  most  of  the  females  were  girlish 
rather  than  womanly  in  contour. 

Results  of  Treatment. — As  regards  the  results  of  treatment 
in  those  .cases,  93  were  discharged  recovered,  or  51  per  cent. ; 
hut  then  40  were  removed  home  or  to  other  institutions  re- 
lieved, many  of  whom  would  have  been  likely  to  recover 
ultimately.     I    only    know    of    26   of    the    180   who   became 


G08    THE   INSANITIES   OF   PUBERTY  AND   ADOLESCENCE. 

incurable.  Insanity  occurring  at  the  adolescent  period  is 
therefore  a  very  curable  disorder  as  compared  with  many 
other  forms,  though  not  so  curable  as  some  forms,  e.g., 
puerperal  insanity.  Just  before  recovery,  in  almost  all  the 
cases  which  did  get  well,  signs  of  physiological  manhood 
appeared,  the  beard  growing,  the  form  expanding,  the  weight 
increasing.  Wlienever  I  see  those  signs,  accompanied  by 
mental  improvement,  I  am  incHned  to  give  a  favourable 
prognosis.  The  mortality  was  very  low,  only  three  of  the 
180  cases  having  died. 

Adolescent  Psychoses  not  amounting  to  Insanity. — There  are 
a  series  of  lesser  mental  and  moral  changes  and  perversities 
short  of  technical  insanity  that  are  Hable  to  occur  in  adoles- 
cents of  both  sexes  with  hereditary  weakness,  often  more 
difficult  to  treat,  frequently  as  distressing  and  always  more 
obscure,  but  all  due  to  the  same  hereditary  and  pathological 
causes  and  of  the  same  essential  nature  as  insanity.  They 
consist  in  some  cases  of  stupidity  and  lethargy,  or  in  an  asocial 
development  when  all  the  social  instincts  should  be  most  keen, 
or  in  causeless  aversions  to  father,  mother,  or  other  near  rela- 
tions, with  intolerance  of  control  and  utter  disregard  of  parental 
feehngs — all  the  time,  perhaps,  getting  on  well  with  strangers 
who  don't  live  mth  the  patient.  Or  we  have  a  general  incom- 
patibihty  of  temper,  the  patient  losing  situations,  quarrelling 
with  friends,  and  making  enemies  everywhere.  Or  it  takes 
the  form  of  visionary  scheming,  or  of  frothy  religionism,  or 
of  sudden  immorahties  contrary  to  the  tenor  of  the  past  life. 
Or  new  and  causeless  immorahties  show  themselves — such  as 
steahng,  violence,  or  murder.  It  is  a  striking  fact  that  one- 
half  of  all  first  convictions  are  in  the  cases  of  offenders  under 
the  age  of  25.  There  seems  to  be  an  adolescent  form  of 
criminality  as  well  as  of  insanity.  Or  perverted  sexual  and 
reproductive  ideas  and  acts  show  themselves.  Sometimes  the 
neurotic  adolescent  shows  a  simple  diminution  of  the  voHtional 
power,  showing  fickleness,  irresolution,  morbid  "laziness," 
and  paralysis  of  voHtion.     I  lately  saw  a  young  gentleman  of 


THE   INSANITIES   OF   PUBERTY  AND   ADOLESCENCE.     609 

20  wlio  said  "something  came  on"  him  that  prevented  him 
using  his  muscle,  so  that,  e.g.,  in  the  midst  of  his  breakfast  he 
could  jLot  raise  the  spoon  to  his  mouth.  I  was  once  consulted 
about  the  case  of  a  lady  who,  up  to  the  age  of  14  or  15,  had 
been  as  other  children,  but  who,  since  that  time,  has  been  the 
despair  of  innumerable  governesses  and  teachers,  and  the 
family  skeleton  at  home.  Clever  intellectually,  especially  in 
defending  her  perverted  conduct  and  in  making  preparations 
to  shock  her  parents,  not  given  to  gross  immorality,  yet  she 
seemed  to  exhaust  all  the  arts  by  which  disobedience,  lying, 
and  outrageous  unconventionalities  of  all  sorts  could  break  her 
parents'  hearts.  She  only  showed  affection  or  consideration 
towards  strangers,  animals,  and  oddities,  and  she  only  professed 
sympathy  with  the  low,  bad,  and  unfortunate.  Respectability 
was  an  unpardonable  offence  to  her.  Yet  she  would  pass 
muster  among  strangers  for  a  month  at  a  time  as  a  clever, 
interesting,  and  original  girl.  She  ultimately  married  one  of 
her  father's  labourers  and  became  a  frugal  farmer's  wife, 
"dropping"  all  her  former  acquaintances. 


2  Q 


LECTUEE   XVII. 

CLIMACTEEIC  INSANITY  {THE  INSANITIES  OF 
DECADENCE). 

The  climactei-ic ;  physiological  and  psychological  characteristics  of  period  ; 
melancholic  symptoms  in  64  per  cent,  of  the  cases,  and  maniacal 
symptoms  in  36  per  cent. — Mental  Symptoms  in  a  typical  case  ;  loss 
of  keen  intei'est  in  life  ;  fits  of  depression  ;  capacity  for  work 
diminished;  irritability;  suspicion;  sense  of  fear  and  impending 
danger;  change  of  connubial  affection  ; -suicidal  longings;  vague 
melancholic  delusions — Bodily  Symptoms :  Sensory  neuroses  ;  ver- 
tigo ;  pains  ;  sensations  of  heat ;  %'aso-motor  neuroses,  flushings, 
&c. — Motor  Symptoms:  Restlessness — 228  climacteric  cases  out  of 
total  of  314.5,  or  7'2  per  cent. — Prognosis:  Fair;  53  per  cent,  of- 
uncomplicated  cases  recover — Treatment :  Change  of  scene  ;  travel ; 
change  of  air  and  of  diet ;  iron  and  quinine  ;  sea-bathing  ;  fresh 
air  ;  fattening  diet ;  the  bromides. 

As  unstable  brains  are  apt  in  certain  cases  to  be  upset  in 
their  mental  functions  by  the  slow  development  of  the 
reproductive  power  and  the  onset  of  the  sexual  function 
at  the  periods  of  puberty  and  adolescence,  so  they  are  apt 
to  suffer  as  those  great  powers  of  the  organism  pass  away 
at  the  climacteric  period.  An  animal  has  functionally  and 
physiologically  three  distinct  periods  of  existence — (1)  when 
its  life  is  dependent  on  that  of  its  mother  before  birth ; 
(2)  when  it  lives  independently,  but  cannot  reproduce  itself, 
before  puberty  and  after  the  climacteric;  and  (3)  when  it 
both  lives  and  can  reproduce.  The  mental  function  is  non- 
existent in  the  first  period,  more  or  less  imperfect  in  the 
second,  and  fully  developed  in  an  ideal  sense  only  in  the 
third.     There  are  some  animals  low  in  the  scale  in  whom 


CLIMACTERIC  INSANITY.  611 

the  reproductive  act  is  always  followed  by  death.  At  the 
period  of  the  climacteric  there  is  unquestionably  a  mental 
change  in  both  sexes.  The  sexual  desire,  after  a  short  period 
of  irritable  aggravation  perhaps,  invariably  weakens  in  its 
intensity  or  ceases  altogether,  and  with  it  the  affectiveness 
changes  in  its  object  and  greatest  intensity  from  the  mate 
to  the  progeny,  losing  its  imaginative  force,  its  fire,  and  its 
impulsiveness.  Poetry  and  love  tales  then  cease  to  have 
the  power  "  to  set  the  brain  on  fire."  Action  of  all  kinds 
ceases  to  be  so  pleasurable  for  its  own  sake  as  it  has  been, 
before.  Much  of  "  the  go "  is  out  of  the  person.  The 
instinctive  feeling  of  difference  of  sex,  and  all  that  it  implies, 
which  has  been  all-pervading  before,  now  lessens  visibly. 
The  subtile  interest  of  the  society  of  the  other  sex  is  less 
electric  and  overmastering.  Along  with  these  afi'ective 
changes  there  are  bodily  changes  too.  The  form  alters, 
especially  in  women,  and  the  expression  of  face  changes,  the 
ovaries  shrivel,  Peyer's  patches  lessen  in  bulk,  and  the  spleen 
and  lymphatic  glands  harden.  The  blood-forming  and  the 
blood-using  processes  slacken  in  speed,  and  the  trophic 
energy  in  all  the  tissues  .  is  less  intense  in  action.  "  Life 
becomes  slower,"  in  fact,  mentally  and  physically.  And  as 
a  result  of  this,  after  the  climacteric  has  been  safely  passed, 
the  organism  is  less  liable  to  many  diseases  than  it  has  been 
before.  The  real  climacteric  in  both  sexes  is  never  a  definite 
fixed  time,  but  usually  extends  over  a  year,  or  two,  or  three, 
or  even  more.  The  mere  cessation  of  the  function  of  men- 
struation in  women  does  not  necessarily  fix  definitely  the 
mental  and  nutritional  changes  that  mark  the  period.  I  have 
known  a  woman  of  50  who  had  gone  through  the  mental 
changes  of  the  climacteric,  in  facial  expression  and  in  form 
was  post-climacteric,  who  had  no  sexual  desire,  yet  was 
menstruating  regularly ;  and,  on  the  other  hand,  I  have 
known  many  women  of  the  same  age,  in  whom  menstruation 
had  ceased  from  40  to  46,  who  were  yet  quite  shapely, 
amorous,  and  mentally  youthful.     So  the  mental  disease  that 


612  CLIMACTERIC   INSANITY. 

accompanies .  the  climacteric  need  not  be  quite  coincident 
with  the  menopause,  but  may  occur  some  time  before  or  some 
time  after  that  event.  As  a  matter  of  fact,  tiie  ordinary 
sensory  nervous  symptoms  that  are  connected  with  the 
chmacteric  in  women,  viz.,  giddiness,  flushings,  flashes  of 
hght,  uneasy  organic  sensations,  &c.,  usually  precede  the 
actual  cessation  of  the  menses  rather  than  accompany  it. 

A  Typical  Case. — A  typical  case  of  climacteric  insanity 
begins  by  a  loss  of  energising  power,  bodily  and  mental,  of 
which  the  patient  is  rather  supersensitively  conscious.  Her 
courage  is  less ;  little  things  come  to  have  the  power  of 
annoying  her  that  she  would  have  thought  nothing  of  before. 
Groundless  fears,  which  at  first  she  knows  to  be  groundless, 
haunt  her  at  times.  And  at  this  stage  the  sleep  is  apt  to  be 
dreamy  and  broken,  the  appetite  for  food  is  less  intense,  and 
the  bowels  costive.  There  is  apt  to  be  some  falhng-off  in 
the  bloom  of  the  complexion  and  in  looks  generally.  The 
skin  often  gets  muddy,  and  more  pigmented  than  usual. 
It  is  a  trouble  for  her  to  go  into  company  or  to  move  about 
in  pubhc,  and  yet  she  has  httle  restful  feeling  and  no  con- 
tentment or  organic  happiness.  At  the  menstrual  times  all 
these  things  are  "much  worse,  and  there  is  apt  to  be  real 
depression  of  mind,  weeping,  with  irritability  of  temper  and 
sleeplessness.  I  have  never  yet  met  with  a  climacteric  case 
in  this  early  stage  who  did  not  feel  much  better  in  the  open 
air  than  in  the  house.  That  is  an  indication  of  treatment 
and  of  prevention  of  further  symptoms  that  I  never  fail  to 
find  usefid.  I  have  seen  iron  at  this  stage,  too,  do  very 
much  good ;  in  fact,  sometimes  it  seemed  to  act  as  a  specific. 
But  those  mental  symptoms  do  not  constitute  insanity,  though 
they  have  a  close  kinship  to  it. 

The  next  stage  consists  of  more  real  and  continuous  depres- 
sion. The  morbid  fears  and  fancies  assume  a  more  intense 
character,  though  they  are  often  still  indefinite.  The  patient 
is  quite  sure  some  CAdl  thing  is  going  to  happen  to  her,  though 
she  cannot  tell  what  it  is  to  be.     The  self-control  is  often  lost, 


/fl 


CLIMACTERIC   INSANITY.  613 

but  much  more  frequently  the  patient  is  terrified  that  it  is 
going  to  be  lost.  There  are  vague  impulses  towards  suicide, 
sometimes  towards  hurting  husband  and  children,  and  the 
existence  of  those  add  to  the  terror  and  intensify  the  depres- 
sion. Such  things  are  thought  by  the  patient  to  be  "  so 
wrong,"  and  she  blames  herself  for  them.  A  conscious  loss 
of  affection,  or  rather  a  loss  of  the  pleasurable  feeling  that 
conscious  affection  for  husband  and  children  gives,  is  a  cause 
of  the  greatest  distress.  There  is  often  a  sort  of  organic 
repugnance  to  the  husband  and  to  his  attentions.  By  this 
time  all  the  usual  sensory  accompaniments  of  the  climacteric 
have  disappeared,  or  rather  they  have  been  transformed  into 
the  mental  neurosis  I  am  describing.  There  are  no  headaches, 
nor  giddiness,  nor  flushings.  But  the  trophic  neuroses  become 
aggravated  all  the  time.  The  thinness,  the  flabbiness  of 
muscle,  the  pigmentation  of  skin,  get  worse.  There  are  fre- 
quently skin  irritations,  and  the  patient  picks  and  scratches 
her  skin.  The  bowels  are  costive,  the  appetite  is  gone,  the 
sleep  absent,  and  the  capacity  for  work  greatly  lessened. 

In  the  worst  cases  suicidal  feelings  are  strong  and  attempts 
frequent,  but  they  are  rather  apt  to  be  feeble.  The  very  loss 
of  courage  and  vigour  of  will  operate  against  any  effectual 
attempts  at  suicide,  however  much  the  wish  may  be  there. 
Hallucinations  of  hearing  are  frequent.  This  condition  may 
pass  into  acute  excited  melanchoha  and  exhaustion,  and  death 
ensue,  or  it  may  become  a  sort  of  chronic  shy  uselessness,  or 
"paralysis  of  energy,"  or  it  may  gradually  pass  away  under 
proper  treatment  and  conditions  of  life,  and  the  woman  be- 
come strong,  cheerful,  well-nourished,  and  useful,  sometimes 
more  "healthy"  in  a  certain  sense  than  ever  before. 

The  following  is  a  case  of  climacteric  insanity,  of  short  dura- 
tion hut  very  acute  form,  and  with  an  element  of  stupor  : — • 

K.  v.,  set.  46,  of  a  cheerful  and  sociable  disposition,  and 
good  habits,  but  with  some  heredity  to  insanity  and  the  neu- 
roses, a  sister  having  been  insane,  and  a  child  having  died  of 
hydrocephalus.     My  impression  is  that,  of  all  the  expressions 


614  CLIMACTERIC   INSANITY. 

of  an  heredity  to  insanity  in  childhood,  hydrocephalus  is,  next 
to  convulsions,  the  most  common.     The  whole  question  of 
the  transmission  of  the  neuroses  to  children  by  mothers  who 
are  then  to  all  appearance  healthy,  and  in  whom  any  nervous 
disease  is  a  mere  potentiahty,  is.  very  interesting,  and  stands 
in  need  of  accurate  observations.     The  weak  and  troublesome 
point  of  all  studies  of  heredity  is,  that  they  cannot  be  regarded 
as  complete  till  all  the  subjects  of  them  are  dead.     K.  V.  had 
over-exertion  of   body  and  anxiety  of  mind  in  nursing  her 
husband  and  through  his  death,  just  as  her  menstruation  was 
becoming  irregular,  this  being  the  exciting  cause  of  her  attack. 
She  had  not  many  of  the  usual  sensory  accompaniments  of  the 
climacteric.     My  experience  is  that  in  the  chmacteric  cases 
with  a  mental  neurosis  the  former  are  often  enough  absent. 
The  one  seems  to  come  instead  of  the  other.     She  never  slept 
well  after  her  husband's  death.     In  about  two  months  there- 
after she  became  depressed,  and  suspicious  that  her  neighbours 
had  an  ill-will  to  her  and  that  every  one  was  against  her.     It 
is  easy  to  see  how  a  lone  neurotic  widow  with  a  family  to 
support  should  take  such  ideas.     But  by  and  by  she  began  to 
fancy  that  her  friends  put  poison  in  her  food ;  no  doubt  this 
was  the  misjudged  sensation  of  the  pain  of  dyspejDsia.     Then 
she  began  to  groan  most  of  the  time,  and  to  cease  to  attend  to 
her  work,  or  to  take  an  interest  in  anything,  her  whole  mind 
being  absorbed  in  her  morbid  thoughts.     On  being  sent  to  the 
Asylum,  she  picked  up  to  some  extent  at  once,  exercising  all 
the  self-control  she  was  capable  of,  the  very  unpalatableness 
of  the  situation  rousing  her.     She  was  thin  and  dark  skinned, 
and  had  a  dull,  listless   look.     Her   sensibility  to  pain  was 
duUed,  there  being  an  element  of  mental  stupor  in  her  case. 
The  tongue  was  furred  and  tremulous,  and  the  bowels  costive. 
Her  pulse  was  88,  and  weak ;  her  temperature  99"3° ;  and  her 
weight  only  8  st.  8  lbs.     She  was  much  depressed  and  con- 
•  fused,  mistaking  the  identity  of  people  about  her.     She  slept 
very  little  at  first.     Her  appetite  was  poor,  and  her  notions 
of    cleanliness  and  decency  were  meagre.     She  was  ordered 


CLIMACTERIC   INSANITY.  615 

quinine  and  iron,  warm  baths,  exercise  in  the  fresh  air,  simple 
laxatives  and  proper  supervision  and  nursing.  In  a  fortnight 
she  was  sleeping  better,  in  a  month  she  was  sleeping  well. 
She  took  plenty  of  food,  occupied  herself  in  useful  work,  and 
her  skin  began  to  look  clearer  and  more  healthy.  Her  fears 
and  delusions  became  vague,  and  with  less  influence  on  her 
demeanour.  She  would  then  take  a  good  fit  of  crying,  which 
did  her  good.  In  another  month  she  had  gained  over  a  stone 
in  weight,  and  was  fairly  convalescent,  and,  being  much  needed 
at  home,  was  sent  there  perhaps  earlier  than  might  otherwise 
have  been  desirable.  The  disease  in  such  short  cases  has 
little  tendency  to  recur.  When  she  left  she  was  getting  the 
post-climacteric  look  in  face  and  form. 

The  following  case  is  one  where  the  symptoms  of  climacteric 
insanity  came  on  several  years  after  the  menopause,  and  were 
never  very  acute,  yet  the  woman  did  not  get  over  them  for  seven 
years.  She  luas  rational  in  conversation,  and  had  no  delusions, 
.  and  her  depression  ivas  by  no  meatis  acute  for  several  years,  hut 
she  was  so  absolutely  devoid  of  initiative  power  and  energy 
that  she  remained  voluntarily  in  the  Asylum,  being  quite  unfit 
to  do  her  work  in  hfe.  K.  W.,  set.  51,  a  widow,  a  healthy, 
cheerful,  active  woman,  who  had  two  children  and  no 
heredity  to  insanity.  About  45,  so  far  as  she  remembers,  she 
ceased  to  menstruate,  this  being  accompanied  by  fearful 
headaches,  feeling  sometimes  as  if  she  would  "  go  out  of  her 
mind."  Those  headaches  continued  more  or  less  up  to- the 
onset  of  her  present  attack  of  melancholia,  but  she  did  not 
change  in  facial  expression,  and  did  not  lose  her  shape,  in 
fact  did  not  exhibit  the  usual  bodily  signs  of  having  passed 
the  crisis,  till  the  depression  of  mind  began  to  appear.  At 
51,  without  any  cause,  she  became  depressed  in  mind, 
nervous,  anxious,  and  fearful.  She  gradually  developed  the 
delusion  that  her  friends  wished  to  take  her  life.  She  was 
sleepless,  and  once  threatened  to  throw  herself  over  the 
window.  She  lost  all  hope  and  courage  and  interest  in  life. 
She  got  occasionally  excited  and  lost  her  self-control,  which 


616  CLIMACTERIC   INSANITY. 

was  the  cause  of  her  being  sent  to  the  Asykim ;  but  during 
the  six  years  she  was  there  she  never  showed  any  sign  of 
excitement,  except  on  one  occasion  shghtly.  She  was  a  dull, 
anxious,  retiring  person,  morbidly  fearful  of  giving  offence, 
and  having  a  dread  on  her  that  something  fearful  Avas 
going  to  happen  to  her.  She  ate  and  slept  well.  She  did 
what  she  was  told  without  interest.  She  had  vague  semi- 
delusional  ideas  that  her  friends  were  all  dead,  that  the 
people  here  seemed  to  be  the  same  as  her  former  friends,  that 
the  things  and  people  about  her  were  not  real.  She  had 
those  feelings,  yet  she  did  not  really  believe  them.  She  had 
pains  and  numbnesses  in  her  joints  and  her  limbs,  probably 
neurotic  in  origin.  She  ate  well, — far  more,  she  said,  than 
she  ever  did  before,— looked  stout  and  well,  slept  Avell,  and 
was  muscularly  strong,  though  not  alert  or  active.  She  led 
a  despondent  life,  with  no  joy  in  it  at  all  and  no  interest  in 
anything,  but  with  little  intellectual  impairment  in. the  sense 
of  dementia.  She  was  very  nearly  but  not  quite  Avell  in  mind. 
I  have  seen  many  such  cases  recover  after  several  years. 
Hers  appeared  to  me  just  an  exaggerated  and  slightly  morbid 
type  of  post-climacteric  physiological  and  psychological  de- 
cadence. 

Some  of  the  cases  take  a  long  time  to  recover.  I  never 
give  up  hope  of  recovery  in  a  climacteric  case  for  five  or  six 
years,  except  there  are  symptoms  of  dementia  or  fixed  de- 
lusions. The  physiological  period  of  life  not  being  a  fixed  nor 
always  a  short  time,  its  nervous  and  mental  accompaniments 
are  often  prolonged  and  irregular. 

The  Climacteric  in  the  Male  Sex. — The  period  of  the  climac- 
teric in  the  male  sex  occurs  at  a  later  time  of  Hfe  than  in  the 
female,  and  is  much  more  irregular  and  indefinite.  There  is 
nothing  to  mark  it  off  so  clearly  as  the  menopause.  Sexual 
power  remains,  but  the  appetite  for  it  is  not  in  normally  con- 
stituted persons  keen  or  pervading,  and  a  diminished  pro- 
creating capacity  remains.  There  is  little  or  no  self-control 
needed   to   restrain  it,  as  in  earlier  years,  and  indeed  it  is 


CLIMACTERIC   INSANITY.  617 

commonly  dormant,  except  when  stimulated.  The  common 
age  for  the  "grand  climacteric"  in  man  is  from  55  to  65,  a 
few  cases  occurring  before  and  after  those  ages.  The  popular 
tradition  puts  it  at  63.  The  procreative  power  of  man  has 
been  demonstrated  by  statistics  to  become  progressively  less 
after  50,  and  to  be  in  reality  small  at  the  later  ages.  The 
normal  mental  change  in  man  is  essentially  the  same  as  in 
woman. 

The  abnormal  mental  changes  that  are  seen  in  some  cases 
at  the  climacteric  period  in  men  are  the  same  in  general  type, 
too,  as  in  women.  The  spontaneity,  the  courage,  the  mental 
aggressiveness,  the  necessity  to  energise  actively,  the  poetic 
sentiment,  the  keenness  of  feeling  in  all  directions,  all  these 
are  impaired.  There  is  no  drawing  towards  the  other  sex, 
and  no  subtile  delight  in  its  presence.  The  sleep  is  less 
sound  and  shorter.  A  cloud  of  vague  depression  rests  on  the 
man,  Avho  shuns  society,  falls  off  in  fat,  becomes  restless  and 
hypochondriacal,  and  feels  strongly  the  tedium  vitas,.  This 
may  go  on  to  suicidal  longings  and  desires,  which  are  usually 
not  very  intense.  In  fact,  nothing  is  intense  with  the  man. 
His  energies,  his  functions,  and  his  vitality  have  all  been 
lowered.  With  this  there  is  no  atheroma,  arcus  senilis, 
or  proper  senility.  But  some  cases  go  on  to  suicidal  and 
resistive  melancholia. 

The  following  Avas  an  aggravated  case  of  climacteric  in- 
sanity in  the  male  sex : — 

K.  X.,  set.  56.  A  quiet  man,  of  melancholic  temperament, 
steady  and  industrious  in  his  habits,  and  with  no  known 
heredity  to  insanity.  Lately  he  had  little  work  and  not 
much  food,  and  was  therefore  anxious  and  underfed.  He 
gradually  became  dull,  and  possessed  with  the  fear  that  some- 
thing dreadful  was  going  to  happen  to  him  and  his  family — a 
fear  founded  on  realities  at  first,  but  gradually  assuming  a 
delusional  character.  He  became  taciturn  and  wearied  of  his 
life,  ceased  to  take  any  interest  in  anytliing,  and  could  not  be 
roused.     One  morning,  just  before  coming  into  the  Asylum, 


618  CLIMACTERIC  INSANITY. 

he  told  his  wife  to  get  up  at  once  and  conceal  herself,  as  he 
had  a  strong  desire  to  kill  her  and  others.  On  admission  he 
said  he  felt  very  badly,  that  strange  and  frightful  ideas  came 
into  his  head  and  preyed  on  his  mind.  One  minute  he  was 
looking  the  picture  of  misery  and  sitting  quite  still,  then  he 
would  lose  control  over  liimself  and  become  restless  and  im- 
pulsive, and  strike  and  bite  those  near  him.  He  was  thin, 
pale,  flabby  in  his  muscles,  and  liis  skin  dark,  muddy,  and 
pigmented.  He  had  been  blistered  at  the  back  of  liis  head 
before  admission — blisters  are  good  treatment  for  some  cases 
of  insanity,  but  not  for  a  half-starved  melanchoHc  workman 
at  the  climacteric.  He  had  a  vague  indefinite  dread  on  liim, 
and  an  absolute  lack  of  interest  in  anything  in  life,  though 
his  memory  and  general  intelligence  were  good.  His  tongue 
was  foul,  his  bowels  costive.  There  were  no  visible  signs  of 
atheroma  of  the  arteries.  He  took  liis  food  fairly  well  at 
first,  and  was  ordered  extra  diet,  porter,  and  Parrish's  syrup 
of  the  phosphates.  He  improved  considerably  for  the  first 
six  months  in  body  and  mind,  but  he  never  got  to  enjoy  life 
or  to  be  sociable.  After  that  time  he  got  worse,  did  not  take 
his  food  well,  and  fell  off  again  in  flesh.  Everything  was  done 
to  improve  liis  appetite,  and  nourishment,  quinine,  cod-hver 
oil,  the  phosphates  and  hypophosphites,  garden  work  and 
amusements,  were  all  tried,  but  he  got  steadily  worse.  He 
became  more  solitary  and  silent.  His  blood  got  so  abnor- 
mal that  at  one  time  purpuric  spots  appeared  over  liis  legs. 
His  delusions  assumed  more  of  a  hypochondriacal  character 
before  his  death,  which  took  place  two  and  a  half  years  after 
admission.  He  thought  all  his  organs  were  diseased,  and  that 
he  had  no  stomach.  He  died  suddenly  at  last,  being  then 
a  mere  skeleton  from  exhaustion.  The  brain  convolutions 
were  found  to  be  atrophied  and  very  anaemic  ;  the  arteries  had 
begun  to  show  the  atheromatous  degeneration ;  there  were 
some  granulations  on  the  floor  of  the  fourth  ventricle,  and  the 
lateral  ventricles  were  dilated  and  filled  with  a  pink  serum. 
There  was  a  patch  of  white  softening,  about  the  size  of  a 


CLIMACTERIC   INSANITY.  619 

filbert,  in  the  centre  of  the  left  hemisphere.  The  aorta  was 
markedly  atheromatous.  This  case  had  not  had  during  life 
any  of  the  distinctively  senile  mental  characters,  yet  the 
pathology  was  undoubtedly  like  that  of  many  senile  cases. 
But  it  was  a  case  of  a  man  slowly  dying  all  over  when  his 
reproductive  energy  failed. 

Of  a  much  onore  common  type  loas  the  folloiving  less  aggra- 
vated case ;— K.  Y.,  set.  57,  a  professional   man,   who  had 
worked   very  hard   indeed.     He   had   a   slight   and  distant 
heredity  to  mental  disease.     His  professional  work  became  a 
burden  to  him,  and  he  lost  all  confidence  in  doing  it,  so  that 
he  had  to  give  it  up.     He  did  not  sleep  well,  became  much 
depressed,    and    was    very    miserable,    obstinate,    and    hypo- 
chondriacal.    He  had  quite  made  up  his  mind  that  he  was 
not  to  get  better,  and  would  do  nothing  towards  his  own 
recovery.-    He   did    not   lose    his    self-control.     He    simply 
changed  his  habits,  avoided  his  friends,  neglected  his  personal 
appearance,  was  absolutely  idle,  and  might  be  said  to  have 
become  morbidly  "selfish."     With  all  this  there  was  appar- 
ently no  lack  of  reasoning  power  or  general  intelligence,  and 
this  made  the  whole  thing  the  more  trying  to  his  friends. 
AVhen  a  man  who  manifestly  cannot  reason  acts  unreasonably 
allowance  is  made  for  him,  but  when  a  man  acts  unreasonably 
who  can  reason,  the  natural  impulse  is  to  blame  him  and  hold 
him  fully  responsible.     Fortunately  he  did  not  give  up  going 
out  into  the  fresh  air,  and  this  was  his  ultimate  salvation,  for 
he  slowly  improved,  and  in  the  course  of  about  five  years  he 
got  perfectly  well,  and  resumed  his  business,  though  he  never 
could  do  as  much,  and  was  never  "  quite  the  same  man,"  but 
was  about  as  happy  as  the  average  of  his  fellowmen  in  their 
post-climacteric.     No  doubt  if  he  had  taken  to  his  bed,  or  to 
staying  in  the  house,  as  so  many  such  cases  do,  he  would 
never  have  recovered.     In  his  case,  as  that  of  many  others  I 
have  met  with,  the  first  decided  symptoms  of  mental  improve- 
ment were  coincident  with  an  eczematous  skin  eruption.     I 
have  seen   gouty,  syphiHtic,  and  all  sorts  of  skin  eruptions 


620 


CLIMACTEKIC  INSAJJTITY. 


come  on  in  sucli  cases  during  the  disease,  usually  greatly  to 
the  patient's  mental  benefit. 

Statistics. — The  prognosis  and  other  points  in  climacteric 
insanity  are  best  brought  out  by  a  statistical"  study  of  a 
number  of  cases.  In  the  nine  years  (1874-82)  I  have  diag- 
nosed as  such  228  cases  of  the  3145  that  have  been  admitted 
into  the  Eoyal  Edinburgh  Asylum  in  that  time.  Of  these  the 
large  proportion  of  196  were  women,  only  32  being  men. 
The  following  table  shows  their  ages : — 


Ages. 

Males. 

Females. 

Total. 

35  to  40 

17 

17 

40    ,,    45 

74 

74 

45    ,,    50 

81 

81 

50   ,,    55 

7 

19 

26 

55    ,,    60 

14 

5 

19 

60   ,,    65 

9 

9 

65   „    70 

2 

2 

32 

196 

228 

We  see  that  by  far  the  majority  of  the  female  cases  occurred 
between  40  and  50,  and  the  majority  of  the  men  between  55 
and  65.  As  regards  the  symptomatological  forms  assumed 
by  the  cases,  only  13  of  the  men  and  56  of  the  women,  or  18 
per  cent,  of  the  whole,  were  acute  in  character.  It  is  essen- 
tially, therefore,  a  subacute  psychosis  in  its  general  character. 
Of  the  whole,  only  82  were  cases  of  mania,  the  remaining  146 
being  melancholic.  One-half  the  patients  were  suicidal  in 
intent  at  least,  but  few  of  them  had  made  very  serious  or 
desj)erate  attempts  to  take  away  their  lives,  though  to  this 
there  were  some  exceptions.  There  was  a  high  proportion, 
but  a  low  intensity  of  suicidal  impulse. 

Curability. — The  results  of  treatment  showed  that  112 
.  cases,  or  53  per  cent,  of  them,  recovered,  the  women  recover- 
ing in  the  largest  proportion.  In  fact,  only  31  per  cent,  of 
the  men  got  well,  while  57  per  cent,  of  the  women  did  so. 


SENILE  INSANITY.  621 

The  numbers  who  died,  on  the  contrary,  were  greater  propor- 
tionately in  the  men  than  the  women,  4  of  the  former,  or  12 
per  celiT;.,  and  17  of  the  latter,  or  9  per  cent.,  having  died  up 
to  this  time.  This  would  seem  to  indicate  that  the  disease  is 
rarer,  less  curable,  and  more  deadly  in  the  male  sex  than  the 
female;  but  the  numbers  are  perhaps  too  few  on  which  to 
base  a  correct  generahsation. 

Duration  of  attacks. — The  patients  who  recovered  had  not 
been  so .  long  ill  as  I  had  previously  imagined.  Taking  the 
time  they  were  under  treatment  in  the  Asylum  (the  only 
correct  basis  I  have  on  which  to  estimate  the  duration),  61 
of  the  122  who  recovered,  or  50  per  cent.,  were  discharged 
within  three  months,  and  80,  or  65  per  cent.,  within  six 
months,  and  111,  or  91  per  cent.,  within  twelve  months. 
There  were  a  few  patients  who  recovered  after  two  years  of 
treatment.  The  maniacal  and  the  melanchohc  cases  recovered 
in  about  equal  proportion,  but  the  maniacal  in  shorter  time. 
The  recoveries  were  much  fewer  in  the  women  over  50,  only 
29  per  cent,  of  these  getting  better.  Up-  to  50  they  recovered 
equally  well.  At  the  other  ages,  from  55  to  60,  the  cases 
were  the  most  curable  in  the  men.  Only  3  of  the  11  over 
60  got  over  their  malady.^ 


SENILE  mSANITY. 

Represents  a  special  intensity  or  an  irregularity  in  the  Physiological 
decay  of  the  brain  ;  premature  and  violent  dotage  ;  relationship  to 
atheroma  of  arteries,  to  shrinking  of  brain,  and  to  degeneration  and 
atrophy  of  cells  of  convolutions — Out  of  3145  cases  203  or  6'4  per 
cent.  Senile  ;  heredity  not  so  common  as  in  other  forms  of  insanity 
— Mental  Symptoms :  Loss  of  memory  ;  irritability  ;  excitement ; 
night  noise  ;  restlessness  ;  one-third  Melancholic,  one-third  Mania- 

1  These  statistics  may  be  profitably  compared  with  those  of  Dr 
Merson's  admirable  paper  on  this  subject,  in  the  West  Biding  Lunatic 
Asylum  Medical  Ileporis,  vol.  vi.  p.  85, 


622  SENILE  INSANITY. 

cal,  and  one-third  slowly  advancing  Senile  Dementiii — Prognosis: 
Bad  ;  not  hopeless  in  all  cases  ;  33  percent,  discharged  from  Asylum 
"  Recovered,"  that  being  a  manageable  mild  dotage  in  many  cases  ; 
snch  "recoveries"  mostly  take  place  in  cases  not  over  75  ;  many 
died  within  the  first  month,  showing  that  the  mental  symptoms 
were  a  part  of  a  general  break-down — Treatment :  Nursing  ;  care  ; 
support ;  sedatives  ;  stimulants  ;  diet — Pathology :  Senile  insanity 
has  a  visible  pathology  in  most  cases  ;  a  gross  lesion,  "softening" 
found  in  42  per  cent. ;  vascular  disease  very  common  ;  atheroma 
and  arteritis ;  atrophy  in  most  cases  ;  apoplexies  in  only  a  few 
cases  ;  miliary  aneurisms  ;  cells  atrophied  and  degenerated  with 
processes  fewer ;  a  general  atrophy  of  neurine  in  some  cases. 

The  psycliology  of  normal  old  age  lias  yet  to  he  written 
from  the  purely  physiological  and  brain  point  of  view.  Poets, 
dramatists,  and  novehsts  have  had  much  to  say  of  it  from 
their  standpoint.  King  Lear  is  beyond  a  doubt  a  truthful 
delineation  of  senihty,  partly  normal  and  partly  abnormal. 
By  normal  senility  I  mean  the  purely  physiological  abatement 
and  decay  in  the  mental  function  running  pari  jpassv,  with 
the  brain  shrinkage  and  the  lessening  of  energy  in  all  the 
other  functions  of  the  organism  at  the  latter  end  of  life.     No 

.  doubt,  in  an  organism  with  no  special  hereditary  weaknesses, 
and  that  had  been  subjected  to  no  special  strains,  all  the 
functions  except  the  reproductive  should  decline  gradually 
and  all  together,  and  death  should  take  place,  not  by  disease 
in  any  proper  sense,  but  through  general  physiological  ex- 
tinction. The  great  function  of  reproduction  stands  in  a 
different  position  from  all  the  other  functions  of  the  organism. 
It  arises  differently,  it  ceases  differently,  and  it  is  more  affected 
in  character  according  to  the  sex  of  the  individual  than  any 
other  function.  It  is,  as  a  matter  of  fact,  not  entirely  de- 
pendent  on  individual  organs.     It  may  exist  as  a  desire  and 

.  an  instinct  without  testes,  or  ovaries,  or  sexual  organs.  It  is 
probably  an  evolution  from  hunger,  as  Clevinger  jjuts  it.  It 
is  really  an  essential,  all-pervading  quality  of  the  whole  organ- 
ism, and  to  some  extent  of  every  individual  organ,  not  one  of 
which  has  entirely  lost  the  primordial  fissiparous  tendency  to 
multiply.     But  the  physiological  period  of  the  cHmacteric  has 


SENILE   INSANITY.  623 

determined  and  ended  it  in  its  intensity  and  greatest  power, 
though  many  of  its  adjuncts  remain;  and  in  the  male  sex  we 
have  .to  reckon  with  it  and  its  abnormal  transformations  to 
some  extent  even  in  the  senile  period  of  life. 

Physiological  Senility.  —  Physiological  senility  typically 
means  no  reproductive  power,  greatly  lessened  affective  faculty, 
diminished  power  of  attention  and  memory,  diminished  desire 
and  power  to  energise  mentally  and  bodily,  lov/ered  imagina- 
tion and  enthusiasm,  lessened  adaptability  to  change,  greater 
slowness  of  mental  action,  slower  and  less  vigorous  speech  as 
well  as  ideation,  impaired  muscularity  and  co-ordination,  a 
changed  tone  of  voice,  fewer  blood-corpuscles  red  and  white, 
lessened  power  of  nutrition  in  all  the  tissues,  a  tendency  to 
disease  of  the  arteries,  a  lessening  in  bulk  of  the  whole  body, 
but  notably  of  the  brain,  which  alters  structurally  and  chemi- 
cally in  its  most  essential  elements,  the  cellular  action  and  the 
nerve  currents  being  slower,  and  there  being  more  resistance 
along  the  conducting  fibres. 

In  the  young  man  there  is  an  organic  craving  for  action, 
which,  not  being  gratified,  there  results  organic  discomfort ; 
in  the  old  man  there  is  an  organic  craving  for  rest,  and  not 
to  gratify  that  causes  organic  uneasiness. 

Dangers  of  Senility, — The  three  great  dangers  to  normal 
mental  senility  are  hereditary  brain  weakness,  a  diseased 
vascular  system,  and  the  effects  of  over-exertion  or  abnormal 
disturbance  of  brain  function  either  at  the  time  or  at  former 
periods  of  life  which  have  left  the  convolutions  weakened. 
Until  the  organ  had  begun  physiologically  to  lose  its  structural 
perfection  and  its  dynamical  force,  the  pathological  phe- 
nomenon that  we  call  mental  disease  was  not  developed.  As 
we  shall  see  from  a  statistical  study  of  clinical  cases,  heredity 
to  insanity  is  less  common  in  the  cases  of  senile  insanity  than 
in  any.  other  form  of  mental  disease  except  general  paralysis  ; 
but  there  is  this  fallacy,  that  the  facts  about  heredity  were 
farther  back  and  more  forgotten  in  this  than  in  any  form. 
An  old  man's  living   relatives   are   few,  and   his .  ancestors' 


624  SENILE   INSANITY. 

history  far  off.  "We  may  put  it  doAvn  as  a  certain  law  of 
nervous  heredity,  that  the  stronger  the  predisposition  the 
sooner  it  manifests  itself  in  life,  and  the  weaker  it  is  the 
later  in  life  it  shows  itself.  To  have  survived,  therefore,  the 
changes  and  chances,  the  crises  and  perils  of  life  with  intact 
mental  function  till  after  60,  means  slight  neurotic  heredity 
or  great  absence  of  exciting  causes  of  disease. 

It  is  impossible  to  fix  an  age  at  which  physiological  senihty 
begins,  and  therefore  we  cannot  fix  an  age  for  senile  insanity. 
Some  men  are  older  at  50  than  others  are  at  70.  I  beheve 
that  in  some  cases  neurotic  heredity  assumes  the  special  form 
of  early  senHity — that  is,  of  early  wear-out  or  poor  organic 
staying  power.  Most  congenital  imbeciles  and  idiots  grow 
old  soon,  many  of  them  dying  of  old  age  at  30.  Many  of  the 
insane  do  so  too,  and  in  many  of  them  the  beginning  of  the 
insanity  is  simply  the  first  expression  of  the  law  of  decay  and 
death.  Premature  age  in  look  characterises  many  of  those 
who  become  insane  after  45.  Yery  many  races  of  men  grow 
old  early,  like  the  Kalmucs  and  Hottentots;  but,  roughly 
speaking,  in  our  race  one  cannot  call  a  man  old  till  he  is  60, 
though  I  have  often  met  with  senile  mental  symptoms  between 
'50  and  60,  and,  as  we  know,  atheromatous  arteries  and  conse- 
quent tissue  degenerations  are  common  enough  before  then. 
But  in  speaking  of  senile  insanity  I  shall  include  no  one  under 
60  years  of  age. 

Statistics. — Only  0"9  per  10,000  of  the  general  population 
under  20  are  sent  to  asylums  in  a  year  in  England  and  Wales, 
while  11*4  per  10,000  over  60  are  so  sent,  or  about  twelve 
times  the  proportion. 

The  best  foundation  for  what  I  have  to  say  of  senile  insanity 
will  be  the  chief  statistical  and  chnical  facts  recorded  about 
203  cases  (71  males  and  132  females)  that  have  been  classified 
under  that  heading  in  the  nine  years'  admissions  to  the  Eoyal 
Edinburgh  Asylum,  1874-82.  The  total  number  of  patients 
admitted  in  that  time  was  3145,  and  they  Avere  of  all  classes, 
from  the  sons  of  peers  of  the  realm  down  to  the  lowest  beggar. 


SENILE  INSANITY.  625 

Of  these,  304,  or  9*6  per  cent,,  were  over  60  years  of  age. 
One  remembers  this  better  by  thmking  that  one-tenth  of  them 
were  'over  60.  But  of  these  304  cases  only  203  were  called 
by  me  senile  insanity.  The  other  101  were  mostly  epileptics, 
old  cases  of  long-existing  mania  or  dementia,  or  cases  of 
climacteric  insanity — that  is,  old  age  had  acted  as  a  pre- 
disposing or  exciting  cause  of  the  mental  disease,  and  the 
symptoms  were  more  or  less  characteristic  of  senility  in 
those  203  cases  only.  Six  and  a  third  per  cent,  of  the 
whole  admissions,  or  one-sixteenth  of  them,  were  thus  cases 
of  senile  insanity.  It  is,  therefore,  a  common,  but  not  the 
most  common,  form  of  insanity,  as  compared  with  the  other 
chnical  varieties  of  mental  disease. 

The  great  predisposing  cause  of  insanity,  heredity,  appeared 
to  be,  as  I  have  said,  very  uncommon.  According  to  our^ 
records,  only  26  of  the  cases,  or  13  per  cent.,  were  so  affected. 
In  estimating  the  frequency  of  heredity  in  mental  disease,  one 
has  to  add  an  enormous  margin  for  ignorance  and  conscious 
or  unconscious  concealment  of  facts.  In  the  nine  years 
under  review,  723  of  the  whole  3145  cases,  or  23  per  cent., 
were  ascertained  to  be  hereditary.  The  senile  heredity,  there- 
fore, was  little  more  than  half  the  ordinary  average  heredity. 

Symptoms  and  Cases. — The  form  assumed  by  the  different 
cases  is  a  question  of  great  interest.  I  confess  I  was  myself 
astonished  at  the  immense  variety  of  mental  symptoms  present. 
Till  I  had  these  203  cases  analysed,  I  had  not  fully  realised 
either  the  character  or  the  results  of  treatment  of  this  disease. 
Looking  first  at  the  presence  or  absence  of  mental  depression 
or  mental  pain,  I  find  that  69  of  these  cases,  or  about  a  third, 
were  depressed,  and  classified  by  me  as  labouring  under 
melancholia.  To  feel  pain,  mental  or  bodily,  the  brain  needs 
to  be  to  a  certain  extent  sensitive  and  active  functionally. 
But  the  peculiarity  of  many  of  the  cases  of  senile  insanity 
was,  that  the  mental  depression  was  merely  outward  in 
muscular  expression,  not  being  felt  in  any  proper  subjective 
sense,  and  it  was  certainly  not  remembered.     It  teas,  in  fact, 

2  R 


/ 


626  SENILE  INSANITY. 

automatic  motor  misery,  and  not  conscioiLS,  sensitive,  tnental 
pain.  One  of  the  cases  lately  under  my  care  illustrates  this 
very  icell : — L.  A.,  set.  83  at  death.  His  mental  power  liad 
been  failing  for  three  or  four  years.  At  first  there  was 
failure  of  memory,  irritabihty,  exaggerated  opinions  of  him- 
self, morbid  suspicions,  sleeplessness,  restlessness,  and  lack 
of  self-control.  These  symptoms  gradually  got  worse,  until 
his  memory  was  quite  gone,  and  he  did  not  know  his  age, 
or  Ms  wife,  or  his  home.  Yet  his  appetite  was  good,  his 
health  in  some  respects  better  than  it  had  been  before,  for  a 
gouty  tendency  had  disappeared.  He  looked  fresh  and  well, 
and  his  muscular  strength  in  spurts  was  very  great  indeed. 
He  had,  a  year  or  so  after  the  beginning  of  the  attack,  a  sort 
of  hemiplegic  attack,  transient  and  shght ;  and  ever  since 
it  began,  and  going  along  with  it  as  one  of  the  symptoms 
of  the  disease,  there  was  a  slight  indistinctness  of  speech, 
a  want  of  motor  activity,  and  of  perfect  co-ordination  in  the 
articulatory  muscles,  a  change  in  the  tone  of  the  voice  in  the 
direction  of  feebleness,  a  difficulty  in  finding  words,  a  ten- 
dency to  stop  in  the  middle  of  sentences,  an  omission  of 
words,  especially  nouns — in  fact,  the  typical  senile  speech, 
Avith  its  mixture  of  aphasic,  amnesic,  and  paretic  symptoms. 
The  senile  speech  I  look  on  as  just  as  characteristic  as  the 
aphasic,  the  general  paralytic,  or  the  hemiplegic  speech, 
and  just  as  illustrative  of  disturbed  brain  function.  He  had 
all  the  signs  of  advanced  atheroma  of  his  vessels. 

About  the  middle  period  of  his  disease  his  memory  was 
quite  gone  for  recent  things,  and  you  could  scarcely  engage 
his  attention  for  more  than  a  few  seconds  on  any  one  subject. 
At  times,  in  fact  mostly,  he  showed  a  kind  of  happy  negative 
contentment.  If  you  could  get  the  thread  of  his  old  life,  he 
would  tell  old  stories,  make  speeches,  and  look  as  wise  as 
possible ;  but  all  this  time  he  did  not  know  who  you  were,  or 
where  he  was,  or  the  day  of  the  week,  or  the  month,  or  the 
year,  or  what  he  had  for  dinner.  Then  suddenly,  mthout 
any   outward  cause,   a    change   would    come   over  him.     He 


SENILE   INSANITY.  627 

would  look  most  miserable,  avouIcI  moan,  and  groan,  and 
weep  (tearlessly),  wring  his  hands,  and  utter  disjointed 
exclamations  of  sorrow ;  but  he  could  not  tell  you  what 
grieved  him,  and  in  a  minute  or  two  he  might  be  quite  cheer- 
ful, and  he  remembered  notliing  about  it,  denying  that  he 
was  at  all  dull  or  ever  had  been  so.  Or  he  would  at  times 
suddenly,  causelessly,  become  intensely  suicidal,  trying  to 
strangle  himself,  running  his  head  against  the  wall,  or 
clutching  his  throat  with  his  hands.  In  that  condition  you 
could  not  rouse  his  attention.  He  was,  in  fact,  practically 
unconscious,  and  AAdien  controlled  or  prevented  carrying  out 
his  suicidal  attempts,  he  would  struggle  and  resist  desperately 
and  unreasoningly.  At  other  times  he  would  have  sudden 
homicidal  attacks.  But  in  half  an  hour  after  all  this  he 
would  be  calm,  chatty,  and  utterly  oblivious  of  everything 
that  had  occurred.  The  whole  thing,  in  fact,  the  pain,  the 
suicidal  and  the  homicidal  impulses,  were  so  many  automatic 
acts  unaccompanied  by  motive,  reason,  or  remembrance,  and 
were  the  mere  motor  signs  of  some  brain  disturbance.  All 
his  worst  symptoms  used  to  come  on  at  night,  when  he  Avould 
become  noisy,  restless,  shouting,  resisting,  and  quite  un- 
manageable, ■  alarming  the  household  and  neighbourhood. 
Those  symptoms  wore  out  every  one  connected  with  him.  Of 
all  forms  of  insanity,  the  senile  is  apt  to  become  most  aggra- 
vated at  night.  It  might  be  supposed  that  there  could 
scarcely  be  any  conceivable  circumstances  under  which  a  man 
over  eighty,  with  means  enough  to  procure  proper  attendance, 
would  have  to  be  sent  from  his  own  home.  Yet  those 
circumstances  occurred.  Home  treatment  was  a  failure,  and 
could  not  be  any  longer  persisted  in.  Certainly  he  did  better 
in  a  villa  of  the  Asylum,  living  by  routine,  with  plenty  of 
fresh  air  and  regulated  exercise  "  little  and  often,"  regularity 
of  life,  lots  of  milk  and  eggs  and  digestible  plain  food,  and 
good  skilled  attendance ;  getting  fat  and  sleeping  far  better. 
But  of  course  he  slowly  got  more  enfeebled  in  mind ;  his 
suicidal  impulses  became  less  intense,  his  noise  at  night  less. 


628  SENILE   INSANITY. 

and  his  resistiveness  more  controllable,  but  liis  motor  restless- 
ness remained.  All  his  symptoms  were  irregularly  periodic 
and  remissional.  Por  months  he  woidd  be  quiet,  and  then 
would  have  a  few  weeks  of  motor  excitement,  and  night  noise 
and  impulsiveness.  What  is  the  cause  of  these  aggravations 
in  senile  cases, — and  they  are  very  common,  almost  universal  1 
I  really  do  not  know.  I  presume  one  must  look  on  them  as 
being  partly  mere  action  and  reaction,  activity  and  exhaustion 
simply.  Are  they  the  results  of  a  brain  habit,  an  organic 
memory  of  the  former  reproductive  periodicity  ?  He  died  of 
senile  exhaustion,  but  with  resistance  to  feeding,  restlessness, 
and  noise  to  some  extent,  up  till  three  days  before  his  death. 

It  is  very  difficult  to  know  how  to  classify  such  a  case 
symptomatologically.  There  was  undoubted  dementia,  and 
there  was  maniacal  excitement.  There  were  all  the  outward 
signs  of  suicidal  melancholia,  and  the  symptoms  of  true  im- 
pulsive insanity.  I  adopt  the  rule,  that  wherever  there  is 
marked  mental  pain,  or  emotional  depression,  or  the  outward 
signs  of  them,  the  case  is  put  down  as  melanchoHa  in  our 
books.  L.  A.'s  case  is  a  typical  example  of  pure  senile 
insanity  of  the  melanchoHc  type.  But  many  of  the  cases  of 
senile  insanity  classified  symptomatologically  as  melanchoha 
were  entirely  different  from  this  case.  Several  of  them  were 
cases  of  simple  melancholia  that  proved  to  be  transient,  its 
only  special  senile  character  being  that  it  occurred  in  old 
people,  was  accompanied  by  more  loss  of  memory  than  usual, 
and  the  recovery  it  ended  in  had  somewhat  of  normal  senility 
in  it.  Several  of  the  cases  were  caused  proximately  by  bodily 
disease  that  exhausted  the  strength  or  lessened  the  blood- 
corpuscles,  or  by  moral  causes.  It  is  quite  common  in  my 
experience,  and,  I  beheve,  in  that  of  all  medical  practitioners, 
to  find  certain  old  persons  much  depressed  in  mind  by  any 
bodily  disease.  Xotably  I  have  seen  tliis  happen  in  the 
course  of  bronchitic  or  heart  troubles,  where  the  blood  was  not 
aerated.  In  fact,  given  a  senile  brain  and  heart,  atheromatous 
arteries,  and  non-aerated  blood,  and  we  are  pretty  certain  to 


SENILE   INSANITY.  629 

have  tlie  mental  functions  of  the  brain  affected.  I  am  in  the 
habit  of  speaking  loosely  of  "  cyanotic  delirium"  and  "cyanotic 
insanity  "  from  the  non-oxygenation  of  the  blood  in  bronchitic 
and  cardiac  disease.  Others  of  my  cases  of  senile  melancholia 
had  fixed  melancholic  dehisions.  Intense  suicidal  feelings 
were  rare,  and  very  determined  attempts  still  more  rare,  but 
we  cannot  depend  on  this  rule  in  all  cases,  for  I  lately  read 
in  the  newspapers  of  the  suicide  of  a  man  of  90.  Of  the 
sixty-seven  melancholic  cases,  seventeen  were  acute  in  symp- 
toms, and  fifty  were  mild. 

Of  the  melancholic  patients,  30  per  cent,  were  discharged 
as  technically  "recovered" — that  is,  in  some  of  them  their 
worst  mental  symptoms  disappeared,  they  passing  into  normal 
senility,  and  in  some  they  became  quite  well  in  an  absolute 
sense.  In  the  melancliolic  patients,  speaking  generally,  the 
recoveries  ivere  apt  to  he  better  than  in  any  other  class  of  senile 
cases,  as  in  the  following  example : — 

L.  B.,  set.  77,  a  man  of  a  reserved  disposition,  steady  and 
temperate  habits.  There  was  no  known  heredity  to  insanity. 
He  had  never  shown  any  disposition  to  depression  of  mind  be- 
fore. He  had  done  his  modest  work  in  life  well ;  had  brought 
up  a  healthy  and  well-doing  family,  and  was  an  intelligent 
and  religious  man.  His  business  was  not  prospering,  and  he 
became  depressed  and  restless.  He  imagined  he  was  eternally 
lost,  that  the  diminution  of  his  business  was  a  direct  judgment 
of  God  for  his  sins.  This,  in  religious  people,  and  in  irre- 
ligious ones  too,  is  a  very  common  melancholic  delusion,  and 
the  public  will  always  have  it  that  any  kind  of  religious  de- 
lusion or  "  religious  insanity  "  is  a  very  bad  symptom  in  every 
case,  and  necessarily  incurable,  l^ow  there  is  only  a  little 
truth  in  this.  The  idea  has  arisen,  no  doubt,  from  the  fact 
that  the  cases  with  fixed  delusions  of  a  religious  kind — the 
prophets  of  the  Lord,  the  sons  of  God,  the  possessed  with  a 
devil — are  usually  incurable,  and  such  cases  make  a  very 
strong  impression  on  the  public  mind.  L.  B.  gradually  got 
Avorse,  and  talked  of  committing  suicide  by  throwing  himself 


630  SENILE   INSANITY. 

over  the  North  Bridge — a  fearfully  suggestive  and  then  low- 
parapeted  place.  After  eighteen  months  of  treatment  at 
home,  he  got  so  ill  that  he  was  sent  to  the  Asylum.  On 
admission  he  Avas  depressed,  restless,  unsettled,  and  talkative, 
with  religious  delusions.  He  looked  an  old  man,  with  athero- 
matous arteries,  and  there  were  senile  cataract  and  marked 
heart  disease ;  but  his  appetite  was  good,  and  his  general 
nutrition  and  strength  very  fair  for  his  age.  He  did  not  sleep 
well  at  first.  He  was  ordered  Parrish's  syrup  of  the  phos- 
phates, cod-liver  oil,  with  milk  diet,  and  fresh  air  when  the 
weather  was  suitable.  There  was  a  hypochondriacal  character 
about  his  mental  depression  all  the  time.  In  about  two 
months  he  had  strengthened  and  improved.  He  became 
more  obviously  concerned  about  the  state  of  his  bowels  than 
that  of  his  soul.  He  was  one  of  the  melancholies  —  a 
numerous  array — who  heard  "the  clock  strike  every  hour 
of  the  night."  In  about  nine  months  he  was  almost  free 
from  the  mental  depression,  and  his  memory  had  got  better, 
while  he  looked  quite  ruddy  and  hale.  In  a  year  he  was 
really  quite  well,  and  Avas  sent  to  his  home  just  as  cheerful 
and  more  active  than  the  average  man  of  78.  He  came  out 
to  see  us  for  three  years  after,  in  no  respect  the  worse, 
mentally  or  physically,  for  his  interlude  of  two  and  a  half 
years  of  senile  depression  and  insanity,  and  he  died  peace- 
fully at  home  in  his  eighty-fourth  year. 

Turning  now  to  the  cases  that  showed  no  melancholic 
symptoms,  or,  at  all  events,  where  such  symptoms  were  not 
long  continued  or  prevailing;  there  were  134  of  these,  all 
of  whom  having  some  sort  of  motor  excitement  were  put  down 
at  first  as  cases  of  "mania."  As  I  do  not  recognise  "de- 
mentia "  to  be  curable  Avhen  used  in  a  correct  sense,  I  scarcely 
ever  at  first  diagnose  any  recent  case  as  such,  no  matter  what 
the  symptoms  are  at  the  time.  To  my  mind,  a  patient  is  only 
proved  to  labour  under  dementia  when,  by  lapse  of  time,  he 
is  seen  to  be  incurable,  and  has  the  symptoms  of  mental  en- 
feeblement  as  Avell.     INIany  of  these   134  senile  cases  were 


SENILE   INSANITY.  631 

really  cases  of  dementia,  but  I  put  them  down  as  mania  at 
first,  because  their  enfeeblement  of  mind  had  not  been  proved 
to  be  incurable,  and  because  they  had  more  or  less  motor 
excitement.  In  only  nineteen  of  these  was  the  excitement  so 
intense  as  to  be  classified  "  acute  mania."  The  mental  symp- 
toms in  these  134  cases,  like  those  of  the  melancholy  cases, 
were  very  difi'erent  in  kind  and  degree,  duration  and  result. 
Some  were  short,  sharp  brain-storms  preceding  death,  outbursts 
of  delirious  excitement  accompanying  the  break-up  of  the 
organism — acute  old  age.  Instead  of  a  long  and  gradually 
progressive  failure  of  convolutional  function,  in  such  cases  it 
ended  in  a  quick  and  tumultuous  fashion.  Instead  of  mere 
loss  of  power  from  innate  trophic  failure  and  want  of  blood, 
in  such  cases  there  is  a  vaso-motor  paralysis  and  a  development 
of  irregular  cellular  energy,  expressed  outwardly  by  constant 
talking,  shouting,  incoherence,  loss  of  memory,  loss  of  atten- 
tion, sleeplessness,  and,  above  all,  by  a  constant  motor  restless- 
ness by  night  and  day,  but  especially  by  night.  This  was 
such  a  case  : — L.  C,  set.  78,  He  had  been  pretty  well  up  to 
three  months  ago,  and  at  that  time  the  excitement  and  exertion 
of  moving  from  one  house  into  another  seemed  to  exhaust  him. 
He  first  became  stupid  and  peculiar,  and  this  came  on  suddenly, 
being  noticed  particularly  one  morning.  He  gradually  be- 
came excited,  incoherent,  threatening,  unmanageable,  and  his 
memory  was  lost ;  but  for  ten  days  only,  before  being  sent 
to  the  Asylum,  had  he  been  very  excited.  The  whole  house- 
hold and  neighbours  were  disturbed  by  his  noise,  and  his 
friends  and  his  doctor  decided  that  he  must  be  sent  to  an 

.  asylum.  On  admission  he  was  weak  muscularly,  spoke  with 
the  voice  and  articulation  of  a  very  old  man;  he  was  con- 
fused, and  his  memory  was  gone.  He  said  he  was  forty,  and 
could  not  answer  almost  any  question  correctly.  His  heart's 
action  was  weak,  and  there  were  moist  rales  heard  all  over  his 
chest,  but  theie  was  no  acute  disease,  his  temperature  being 
98'4°,  and  his  pulse  80.  The  left  side  of  his  face  was  slightly 
paralysed,  and  his  pupils  unequal.     There  was  no  paralysis  of 


632  SENILE   INSANITY. 

arms  or  legs.  He  did  not  sleep,  and  was  noisy  and  excited 
all  niglit.  There  was  much  difficulty  in  making  him  take  his 
food,  too.  His  bronchitis  was  bad,  and  his  cough  very  trouble- 
some. Within  forty-eight  hours  after  admission  he  got 
pale  and  weak,  his  breathing  became  laboured,  and  he  died 
suddenly  that  day.  There  was  no  post-mortem  examination. 
His  relatives  naturally  were  very  sorry  they  sent  liim  to  the 
Asylum,  and  were  inclined  to  blame  the  doctor  who  recom- 
mended it.  Xo  doubt,  if  the  result  could  have  been  foreseen, 
no  one  would  have  recommended  his  leaving  home,  but  I  do 
not  think  there  were  any  definite  symptoms  present  pointing 
to  the  result.  When  consulted  about  cases  of  senile  insanity, 
I  always  have  before  my  mind  the  question — "Are  those 
mental  symptoms  not  the  mere  forerunner  and  accompani- 
ment of  a  general  break-up  ? "  And  to  answer  that  question 
it  is  desirable  to  go  into  the  condition  of  the  brain,  the  heart, 
the  lungs,  the  kidneys,  and  the  general  strength  very  care- 
fully. I  am  always  suspicious  of  sudden  oncomings  of 
mania  in  old  people  being  of  this  character. 

The  follmcing  se?iile  case  icas  typical  iii  its  inception,  symp- 
toms, incidents,  duration,  and  pathology : — L.  D.,  set.  78. 
Had  been  hard-working,  and  as  drunken  as  his  limited  means 
would  allow.  Senile  insanity  is  often  the  penalty  for  an  ex- 
cessive use  of  alcohol  in  earher  life.  About  nine  months  ago 
he  got  a  fall  down  stairs,  and  has  not  been  so  strong  or  well 
since.  About  six  months  ago  his  memory  began  to  fail,  then 
he  became  stupid  and  confused,  then  suspicious,  then  restless, 
then  unmanageable,  then  violent  to  his  wife,  and  was  then 
sent  to  the  Asylum  as  a  pauper  patient.  On.  admission  he 
was  confused,  slightly  excited,  very  restless,  his  memory  gone, 
his  general  condition  weak,  his  senses  blunted,  his  speech 
senile,  his  pupils  irregular  in  outline,  his  tongue  tremulous, 
his  pulse  90,  weak  and  intermittent,  his  temperature  98 "2°, 
his  lungs  and  other  organs  healthy,  and  his  appetite  good. 
He  was  well  fed  and  nursed  in  our  hospital  ward,  but  though 
he  gained  in  flesh  he   did  not  improve.     He   was  restless,- 


SENILE  INSANITY.  633 

especially  at  night,  became  gradually  dirty  in  his  habits, 
moved  about  in  a  purposeless  way  all  the  time.  The  motor 
restlessness  of  a  senile  case  is  an  extraordinarily  vital 
phenomenon.  He  never  sits  down,  seldom  sleeps,  he  shouts, 
and  walks  about  his  room  all  night,  and  yet  never  tires.  I 
found  that  this  symptom  existed  in  60  per  cent,  of  all  the 
cases.  Whence  the  source  of  all  this  most  unnatural  muscular 
energy  1  It  exhausts  his  small  stock  of  real  strength,  though 
he  does  not  feel  it.  It  is  the  antipodes  of  the  quietude  and 
disinclination  for  exertion  of  the  normal  old  man.  It  must 
mean  that  in  the  brain-cells  the  normal  inhibition  over  the 
evolution  of  energy  is  lost.  Instead  of  being  stored  up,  it  is 
let  out  all  the  time. 

About  three  months  after  admission,  as  he  was  aimlessly 
carrying  a  chair  in  the  day-room,  he  slipped,  falling  down  and 
breaking  his  right  femur  at  the  neck  inside  the  capsule,  an 
accident  always  liable  to  happen  to  a  restless  senile  patient. 
He  got  on  pretty  well,  being  left  in  bed  and  nursed  and  cared 
for  as  well  as  was  possible.  In  about  two  months  the  restless- 
ness came  on  again,  and  in  trying  to  rise  he  hurt  his  leg  again. 
In  about  a  month  he  died  of  exhaustion,  having  been  ill  for 
ten  months.  There  was  much  difficulty  in  preventing  the 
formation  of  bed-sores  before  death.  The  difficulty  of 
managing  such  cases  satisfactorily  in  an  asylum  or  out  of 
it  is  extreme.  They  are  very  restless,  always  meddling  with 
something  or  somebody,  very  obstinate,  entirely  forgetful  and 
purposeless.  They  are  constantly  making  their  water  on  the 
floor,  in  a  corner  of  the  room,  or  in  another  patient's  hat. 
They  need  bathing  often.  Their  bowels  are  either  too  costive 
or  too  loose.  They  are  liable  to  retention  of  urine  from 
enlarged  prostate  and  bladder  paralysis.  They  either  eat  too 
much  or  will  not  eat  at  all.  A  slight  fall  breaks  their  bones. 
To  be  near  other  maniacal  or  irritable  patients  is  out  of  the 
question,  for  they  are  sure  to  get  hurt.  For  them  one  requires 
to  use  the  best  attendants,  the  best  single  rooms  at  night,  and 
the  best  parts  of  a  fully  equipped  hospital  ward ;  and  all  this 


634  SENILE  INSANITY. 

needs  to  be  done  by  nurse  and  doctor  under  the  depressing 
feeling  that  it  is  of  no  use  in  the  long-run  towards  the  cure 
of  the  patient. 

On  a  post-moiiem  examination  of  L.  D.'s  case  the  pia  mater 
and  arachnoid  were  found  thick  and  opaque,  but  stripping 
freely  off  the  convolutions,  which  were  over  the  vertex  of  the 
brain  atrophied  and  covered  with  an  opaque   compensatory 
fluid.     On  section  the  grey  substance  of  the  convolutions  was 
irregularly  thinned  and  soft  in  texture,  the  perivascular  canals 
being  enormously  enlarged.     In  the  extra-ventricular  nucleus 
of  the  left  corpus  striatum  there  Avas  a  recent  hsemorrhage,  the 
size  of  a  pea,  and  in  the  right  optic  thalamus  one  of  the  same 
size  of  older  date.     There  was  a  small  softening  from  embolism 
or  thrombosis  in  another  part  of  the  thalamus.     The  Hning 
membranes  of  all  the  ventricles  were  granular,  and  the  lateral 
ventricles  were  enlarged  from  interstitial  brain  atrophy.     All 
the   brain    arteries    were    atheromatous   in   patches,   causing 
diminution  of  their  lumen  at  these  points.     There  was  dila- 
tation of  both  ventricles  ;  the  aorta  was  very  atheromatous, 
lungs  oedematous,  Hver  slightly  nutmeggy,  right  kidney  dis- 
organised and   the  seat  of   an  extravasation  of   blood.     On 
microscopic  examination  the  large  cells  in  the  inner  layers 
of  the  convolutions  were  found  in  a  degenerated  atrophied 
state,    with    their    processes    gone     (Plate    II.    fig.     5    and 
Plate   XV.    fig.    9).      There   was   much   debris    round    the 
vessels  in  the  perivascular  canals.     In  some  few  of  the  cases 
the  pathological  appearances  are  indicative  of  a  much  more 
intensely  disturbed  state  of  the  convolutions  during  life.     Eor 
instance,  in  a  case  I  examined,  L.  E.,  set.  76,  who  had  been 
ill  for  fifteen  months,  the  last  three  of  which  were  spent  in 
the  Asylum,  and  who  had,  in  addition  to  the  symptoms  of 
the  last  case,  great  violence  at  times,  wanting  to  get  out  of 
his  house,  which  he  maintained  was  not  his  own,  an  epilepti- 
form   attack,  a    very   indistinct,    thick,    scarcely  intelligible 
articulation,  all  his  symptoms  remissional,  great  emotionalism, 
and  a  temperature  of  from  99°  to  100°,  we  found  after  death 


SENILE   INSANITY.  635 

great  adherence  of  the  dura  mater  to  the  skull-cap,  and  a  very 
dark-coloured  false  membrane,  varying  from  a  quarter  of 
an  iiich  in  thickness,  covering  the  whole  of  the  vertex,  and 
descending  down  and  covering  the  base  in  a  thin  layer.  In 
this  membrane  there  were  several  pure  blood-coagula,  from 
the  size  of  a  pea  up  to  that  of  a  small  walnut.  The  pia  mater 
was  not  adherent — though  in  two  or  three  senile  cases  I  have 
found  it  to  be  so — the  ventricles  were  granulated,  and  there 
was  much  general  atrophy.  There  was  hypertrophy  of  the 
muscular  substance  of  the  heart  and  aortic  incompetence. 

The  following  is  a  case  of  transient  senile  mania  ending  in 
recovery : — L.  F.,  set.  63,  a  man  of  a  cheerful  disposition  and 
somewhat  intemperate  habits.  By  the  way,  liquor  undoubt- 
edly affects  an  old  man  far  more  than  a  young  one  in  the  di- 
rection of  producing  insanity  as  well  as  less-marked  neuroses. 
It  tends  more  towards  tissue  degeneration  at  advanced  ages, 
and  the  nerve  tissue  suffers  most  in  neurotic  subjects.  There 
was  some  insanity  in  the  family,  but  he  came  of  an  otherwise 
sound,  long-lived  stock.  Three  months  ago  he  had  an  old 
ulcerated  leg  healed  up.  Had  a  perineal  abscess  a  fortnight 
ago,  which  was  opened,  and  since  then  has  been  affected  in 
mind.  The  attack  is  recent,  and  came  on  suddenly.  He 
began  to  take  fancies  that  he  was  rich,  got  excited,  and  had 
a  great  craving  for  drink,  which  he  indulged,  and  got  much 
worse  after  it.  On  admission  he  was  greatly  exalted,  saying 
he  was  possessed  of  all  knowledge,  power,  and  wealth.  He 
was  excited,  shouting  and  crying,  said  he  was  the  "  Messiah 
God,"  that  he  had  millions  of  money.  He  did  not  sleep,  and 
his  appetite  Avas  poor.  He  was  dirty  in  his  habits,  and  con- 
stantly restless.  He  was  fed  well,  and  got  tonics,  chiefly  iron 
and  quinine.  Within  a  month  he  was  quiet  and  almost 
rational  and  free  from  delusions.  In  about  three  weeks  more 
he  began  to  suffer  from  headaches,  and  soon  became  melan- 
cholic and  morbidly  anxious  about  his  health.  Aft:.r  having 
begun  to  sleep  well,  he  again  lost  the  power  of  sleeping  in 
this  melancholic  stage.     In  about  another  month  he  gradually 


636  SENILE   IXSAiSlITY. 

got  out  of  the  depression,  and  passed  into  a  quietly  contented, 
rational,  sane  senility.  He  went  home,  and  ended  his  days 
in  peace  after  some  years.  He  entered  on  the  attack  a 
raiddle-aged-looking  man  ;  he  came  out  of  it  visibly  an  old 
man  in  body  and  mind,  but  in  no  respect  a  dotard  or  unfit  to 
manage  liis  affairs  in  a  quiet  way.  This  was  a  case  of  senility 
ushered  in  by  brain-storm.  Mentally  he  at  first  resembled 
a  typical  general  paralytic,  and  this,  with  the  slurred  indistinct 
speech  of  senility,  often  causes  a  mistake  in  one's  diagnosis 
even  in  a  case  over  60. 

Looking  at  senile  insanity  broadly,  there  is  no  doubt  that 
its  pure  type  is  to  be  found  in  the  restless,  sleepless  dotard, 
without  memory,  without  true  affectiveness — at  the  beginning 
of  the  disease  there  is  often  affective  hypersesthesia  and 
TincontroUable  emotionahsm — without  crisp,  articulate  speech, 
second  childhood  in  an  unmanageable  form,  in  fact.  That 
is  the  true  senile  dementia,  out  of  which  there  can  be  no  issue 
but  death.  Of  this  class  of  case  there  were  in  a  typical  form 
62  cases  of  the  203,  or  30  per  cent.  That  statistical  result 
was  a  surprise  to  me.  I  had  expected  more  of  that  type. 
Some  of  the  others  seemed  to  be  of  that  character  at  one 
period  of  their  attack,  but  they  came  back  to  something  like 
normal  mUd  senihty.  As  might  have  been  expected  on 
physiological  grounds,  the  typical  cases  of  senile  dementia 
Avere  found  in  greatest  numbers  at  the  more  advanced  ages, 
biit  from  60  up  to  75  there  was  no  regular  increase  in  their 
number.  Under  75  there  were  over  18  per  cent,  of  typical 
dotards ;  over  75  there  were  only  50  per  cent. 

Some  of  the  cases  were  quite  strong  in  body,  and,  beyond 
some  arterial  degeneration,  showed  no  signs  of  bodily  disease, 
and  their  mental  condition  was  a  cheerful,  forgetful  enfeeble- 
ment.  I  have  one  such  man  of  70,  as  good  a  garden  worker 
as  we  have,  who  sleeps  well  and  eats  well,  but  cannot  tell  you 
the  day  of  the  week,  calls  me  an  old  friend,  and  has  no  idea 
where  he  is.  Another  marked  type  is  that  of  pure  senile 
elevation,  with  delusions  of  great  possessions  and  power,  as 


SENILE  INSANITY.  637 

in  L.  F.'s  case.  Sucli  delusions,  existing  along  with  mild 
maniacal  exaltation  and  senile  articulation,  constitute  those 
cases  resembling  general  paralysis.  They  are  constantly 
diagnosed  as  such,  in  my  experience.  But  general  paralysis 
scarcely  ever  appears  after  60,  and  never  after  65.  A  close 
study  of  the  speech,  too,  will  usually  determine  the  difference. 
There  is  not  the  true  general  paralytic  fibrillar  trembling,  nor 
the  spasmodic  convulsions  of  the  smaller  facial  and  labial 
muscles.  Quite  a  number  of  the  cases  were  of  that  type  in 
the  early  period  of  their  disease.  One  such  case  of  65,  A. 
H.,  had  millions  of  money ;  the  Asylum  belonged  to  him ;  he 
would  give  you  a  thousand  pounds  for  the  asking;  he  was 
happy  as  a  king,  and  he  was  constantly  restless,  pulling  off 
his  buttons  and  taking  off  his  clothes.  His  speech  was  thick, 
hesitating,  and  wanting  in  crispness  of  tone.  He  gradually 
became  hemiplegic,  and  died  in  about  two  years,  a  dotard. 
A  large  embolic  softening  was  found  in  his  corpus  striatum, 
as  well  as  several  smaller  softenings  in  the  convolutions  of 
the  motor  area  of  the  cortex. 

Lewis  points  out  that  there  are  a  few  cases  of  senile  con- 
vulsions and  epilepsy  causing  or  combined  with  mental  symp- 
toms.^ I  once  saw  an  old  lady  of  80  who  at  first  had 
hallucinations  of  sight  and  knew  the  things  she  saw  were 
unreal,  though  they  were  most  vivid.  When  her  daughter 
would  be  at  the  door  she  would  see  another  figure  of  her  on 
the  opposite  side  of  the  room,  and  would  not  be  able  to  dis- 
tinguish the  real  from  the  spectral  daughter. 

Many  senile  cases  have  hallucinations  of  hearing  and  of 
sight.  I  have  now  two  old  women  who  hold  regular  conver- 
sations Avith  people  in  the  ceiling  and  in  the  next  room.  Some 
of  the  men  develop  a  morbid  eroticism  and  a  physiological 
immorality.  I  have  known  several  marriages  to  be  made  by 
commencing  senile  dements.  I  had  one  patient  of  80,  L.  G., 
whose  conduct  towards  his  female  nurses  was  so  bad  that  few 
respectable  women  could  be  got  to  look  after  him,  and  yet  he 
1  Op.  cit. ,  p.  408. 


638 


SENILE  INSANITY. 


was  of  tlie  melancholic  type,  "just  going  to  die"  every  day. 
Masturbation  is  not  unknown  in  senile  insanity.  The  hypo- 
chondriacal mental  symptoms  that  are  certainly  one  of  the 
most  characteristic  features  of  the  cases  of  chmacteric  insanity 
are  sometimes  seen  in  senile  cases.  In  most  cases  there  are 
morbid  suspicions  at  the  beginning.  I  had  an  old  lady  patient 
who  dismissed  her  old  faithful  servant  two  or  tliree  times  a 
week  for  stealing  her  clothes.  I  saw  one  lately  who  believes 
that  her  neighbours  come  into  her  house  and  plot  to  rob  her 
of  her  money.  The  characteristic  of  the  senile  suspicions  is 
that  they  refer  to  things  that  are  possible  to  happen,  to  steal- 
ing of  clothes  or  money,  to  faithlessness  on  the  part  of  near 
relations,  &c.,  and  do  not  refer  to  the  impossible  tilings  that 
cases  of  real  monomania  of  suspicion  believe,  to  electric  and 
mesmeric  agencies,  or  to  elaborate  social  plots.  The  senile 
cases  are  constantly  changing  in  their  suspicions  and  fancies, 
too ;  one  day  it  is  one  thing,  another  day  another. 

In  a  few  of  the  cases  food  is  refused — a  very  troublesome 
and  a  very  grave  symptom.  To  feed  an  old  man  or  woman 
by  the  nose  or  stomach  tube  does  not  seem,  somehow,  to  be 
followed  by  such  good  results  as  the  forcible  feeding  of  younger 
patients.  The  mucous  membrane  of  the  mouth  and  fauces  is 
apt  to  get  dry,  and  diarrhoea  to  set  in.  In  two  or  three  cases 
Jujematoma  auris  developed  during  the  acutely  maniacal  stage, 
this  no  doubt  indicating  marked  vascular  disease  and  trophic 
disturbance. 

Ages. — The  ages  of  the  cases  are  best  seen  by  a  glance  at 
the  table  below.^     Taking  the  whole  number  of  cases  (203), 


Age. 

Total  Xos. 

Recovered. 

60  to  65 
65    „    70 
70   ,,    75 
75   „    80 
80   ,,    85 
85   ,,    90 

62 
63 
40 
30 
3 
5 

24 

21 

15 

9 

1 
2 

203             1             72             1 

1 

SENILE   INSANITY.  639 

over  60  per  cent,  of  them  were  between  60  and  70,  35  per 
cent,  were  between  70  and  80,  and  about  4  per  cent,  over  80. 
That  is'  not  far  from  the  proportion  at  those  ages  in  the 
general  population  over  60.  The  chief  difference  is  that  the 
proportion  of  insane  persons  between  70  and  80  is  greater, 
while  the  proportion  of  the  sane  over  80  is  double  that  of 
the  insane. 

Curability. — One  of  the  most  interesting  and  important 
of  the  results  I  obtained  from  an  analysis  of  those  203  senile 
cases  was  a  clearer  idea  than  I  had  before  of  the  course  of 
such  cases,  their  duration,  and  the  results  of  treatment. 
The  general  result  was  that  seventy-two  of  the  cases,  that 
is,  35  per  cent,  of  them,  were  discharged  from  the  Asylum 
recovered ;  and  sixty-nine  cases,  that  is,  33  per  cent.,  have 
died :  while  thirty-three  cases  were  discharged  more  or  less 
improved  or  not  at  all  improved,  leaving  twenty-nine  cases 
under  treatment.  The  striking  fact  is  the  number  of  re- 
coveries. I  must  explain  that  the  "  recovery "  from  any 
form  of  senile  insanity  need  not  necessarily  be,  and  is  not 
as  a  matter  of  fact  an  absolute  restoration  to  pristine  vigour 
of  mind.  Some  such  complete  recoveries  there  were,  men 
who  went  out  and  earned  their  own  livelihood,  women  who 
went  out  and  governed  their  households.  But  such  cases 
were  usually  the  short  attacks  of  exaltation  or  depression 
that  I  have  referred  to.  They  mostly  occurred  between 
the  ages  of  60  and  75,  though  they  were  not  absolutely 
unknown  after.  At  least  one-half  of  the  recoveries,  perhaps 
rather  more,  were  returns  to  or  gradual  passings  into  mild, 
manageable,  normal  senility.  That  is  all  that  can  be  expected 
in  a  case  with  the  typical  characters  of  senile  insanity.  It 
is  all  I  ever  lead  the  relations  to  expect  will  occur.  But 
it  is  a  most  happy  change  from  senile  mania.  To  have 
an  aged  father  or  mother  pass  out  of  such  a  condition, 
and  become  fit  to  go  home  and  be  lovingly  cared  for  till 
death  takes  place,  is  an  occurrence  for  which  most  persons 
of    proper    feeling    will    be    profoundly    grateful.       When 


640  SENILE   INSANITY. 

sucli  a  return  to  normal  senility  occurs,  there  is  usually 
little  tendency  for  the  excitement  to  return  under  proper 
care  and  feeding. 

The  recovery  rate  in  each  quinquenniad  from  60  to  75  was 
about  the  same,  and  the  rate  in  that  whole  period  of  fifteen 
years  was  36  per  cent.,  or  sixty  cases  out  of  165.  The 
numbers  in  each  of  the  next  quinquenniads  were  too  small 
to  give  results  worth  generalising  on,  but  the  total  number 
of  recoveries  in  the  thirty -eight  cases  over  the  age  of  75  was 
twelve,  or  at  the  rate  of  32  per  cent.  This  last  was  one  of 
the  results  that  surprised  me,  I  confess. 

Duration  of  Attack. — The  recoveries  took  place  in  about 
the  usual  time  that  recoveries  from  other  forms  of  insanity 
take  place.  About  one-half  (47  per  cent.)  of  them  were 
discharged  recovered  within  three  months  of  residence,  and 
over  three-fourths  (79  per  cent.)  of  them  within  six  months. 
In  fact,  rather  a  larger  number  recovered  within  six  months 
than  the  average  recoveries  in  an  asylum. 

Mortality. — Sixty-nine  of  the  203  cases  have  died  up  to 
this  time.  There  is  much  risk  of  them  dying  within  the  first 
month, — this,  of  course,  meaning  that  in  a  considerable 
number  of  cases  the  mental  disease  is  of  the  nature  of  an 
ante-mortem  delirium,  hke  L.  C.'s  case  I  have  related.  Seven 
per  cent,  of  the  cases  died  within  the  first  month,  making 
about  20  per  cent,  of  the  whole  of  the  deaths.  Far  more 
died  in  the  first  than  in  any  subsequent  month.  More  than 
half  the  deaths  occurred  within  the  first  six  months  of 
residence,  that  being  a  considerably  earlier  period  of  death 
than  in  most  other  forms  of  insanity. 

Pathology  of  Senile  Insanity. — The  pathology  of  the  disease 
is  interesting  because  it  has  some  approach  to  definiteness.  It 
is,  next  to  general  paralysis  and  paralytic  insanity,  the  form  of 
mental  disease  in  wliich  the  grossest  pathological  appearances 
are  found  in  the  brain.  Out  of  the  ninety-two  deaths  we 
were  allowed  to  have  post-mortem  examinations  in  fifty-two 
cases.     I  often  find  it  unusually  difficult  to  obtain  permission 


SENILE   INSANITY,  641 

for  post-mortem  examinations  in  senile  cases.  An  exhaustive 
analysis  of  the  pathological  appearances  found  in  these  fifty- 
two  -cases  would  he  far  too  tedious  to  attempt.  Many  of  the 
cases  would  need  a  special  description  to  do  them  justice. 
All  I  shall  attempt  is  a  summary  of  the  chief  appearances. 
The  most  common  of  all  the  lesions  found  in  the  brain  itself 
was  that  form  of  combined  cerebro- vascular  disease,  "  soften- 
ing of  the  brain,"  This  occurred  in  a  marked  form  in  twenty- 
two  cases,  or  42  per  cent,  of  the  whole.  I  need  hardly  say 
that  I  use  the  term  in  the  proper  sense  of  a  ramollissement,  a 
locahsed  necrosis,  partial  or  entire,  of  a  portion  of  brain  tissue, 
resulting  in  most  cases  from  a  deprivation  of  blood  through 
embolism  or  thrombosis  of  the  arterial  branches  supplying  it. 
In  every  case  of  softening  there  was  marked  vascular  disease, 
and  in  many  cases  the  obstructed  vessel  that  had  formerly 
supplied  the  starved  portion  of  brain  could  be  demonstrated. 
Commonly,  the  form  of  vascular  disease  was  atheroma  in  an 
advanced  form,  sometimes  aneurisms,  large  and  small,  some- 
times inflammatory  general  thickening  of  the  coats  of  the 
vessels.  The  softenings  were  commonly  localised  and  seldom 
very  extensive,  in  this  difi'ering  markedly  from  the  softening 
found  in  the  brains  of  younger  insane  persons.  They  were 
found  everywhere,  but  the  most  common  sites  were  the  great 
basal  ganglia,  notably  the  corpus  striatum,  and  the  convolu- 
tions of  the  vertex  and  lateral  portions  of  the  anterior  and 
middle  lobes. ^  The  appearances  of  the  softenings  were  very 
difierent  in  different  cases,  according  to  their  duration  and 
the  sudden  or  gradual  onset  of  the  lesion.  When  a  twig  of 
a  cerebral  artery  is  suddenly  obstructed  by  an  embolic  plug, 
most  of  the  tissue  supplied  by  it  dies  at  once,  a  sort  of  inflam- 
matory process  (the  "  red  softening  "  of  the  older  pathologists) 
taking  place  for  a  fcAv  days  at  first.  Then  it  liquefies  from 
the  centre  outwards,  appearing  as  the  typical  "  white  soften- 
ing," the   process  usually  tending  to  spread  into  the  sound 

^  See  a  very  careful  analysis  of  the  positions  of  brain  softening  in  the 
insane  by  Lewis.     Op.  cit.,  p,  450. 

2  R 


642  SENILE   INSANITY. 

tissue ;  but  sometimes,  if  the  dead  portion  is  very  small,  the 
debris  gets  partly  absorbed  and  the  tissue  round  it  sacculates, 
or,  in  still  rarer  instances,  shrinks  together,  forming  a  con- 
densed cicatrix-looking  spot.  But  no  doubt  the  common 
thing  is  slow  progression  of  the  softening,  in  accordance  with 
that  fatal  law  of  progressive  nerve-tissue  degeneration  first 
described  by  Waller  in  the  peripheral  nerves,  and  which  has 
since  been  found  to  exist  in  so  many  nervous  diseases.  In 
senile  cases  the  softening  process  is  commonly  gradual  through 
the  slow  starvation  of  an  area  of  brain  tissue  from  a  gradual 
atheromatous  diminution  of  the  lumen  of  its  supplying  vessel. 
I  did  not  at  one  time  believe  in  a  non-syphilitic  senile  arteritis 
affecting  all  the  coats  of  the  vessels.  K'ow  I  do,  for  I  have 
seen  it.  And  I  know  of  no  test  to  distinguish  such  arterial 
disease  from  syphiHtic  arteritis.  In  that  case  there  is  no 
preliminary  red  softening,  but  a  slow  absorption  of  the  neu- 
rine  tissue,  giving  the  appearance  at  first  of  a  spongy  grey 
area  (see  Plate  I.  fig.  5)  and  going  on  to  its  complete  atrophy 
and  disappearance.  The  appearances  caused  by  the  sudden  and 
the  gradual  starvation  process  difi'er  much  in  the  convolutions 
and  the  white  substance.  The  former  having  about  five  times 
the  blood-supply  of  the  latter,  it  is  far  more  apt  to  be  fiUed  with 
haemorrhagic  debris  in  the  sudden  cases,  and  to  have  a  grey, 
dirty,  gelatinous  look  in  the  gradual  cases.  The  convolutions 
or  parts  of  convolutions  afi'ected  look  wasted,  the  pia  mater 
comes  off  readily,  and  to  the  touch  their  resistance  is  very 
soft.  It  is  difficult  to  harden  them  even  in  spirit.  The  chief 
blood-supply  of  the  convolutions  being  derived  from  small 
arterial  twigs  from  the  pia  mater,  each  twig  not  anastomosing 
much  with  the  others,  but  nourishing  a  small  convolutional 
area  of  its  own,  if  one  of  these  be  obstructed  its  area  dies  and 
softens,  slowly  or  quickly,  according  to  the  kind  of  obstruc- 
tion. But,  as  Duret  and  Heubner  show,  the  convolutions 
have  a  second  blood-supply  from  within.  We  do  not  find 
the  complete  necrosis  of  tissue  in  the  grey  that  is  found 
in    the    white   substance.      The    former    commonly   retains 


SENILE   INSANITY.  643 

some  vitality,  and  almost  never  becomes  a  liquid  pulp,  or 
altogether  disappears,  like  the  white  substance,  from  this 
cause.  ■  ' 

The  next  notable  appearance  observed  was  marked  atrophy 
of  the  whole  brain,  or  of  considerable  portions  of  its  convol- 
utional  surface.  This  existed,  alone  or  in  conjunction  with 
other  lesions,  in  so  marked  a  degree  as  to  be  put  down  as  one 
of  the  direct  causes  of  death  in  twelve  cases,  and  in  a  lesser 
degree  in  most  of  the  others.  No  doubt  this  atrophy  is 
partly  the  same  process  as  softening,  only  the  starvation 
process  is  slower  still,  and  is  partly  owing,  not  to  a  diminished 
blood-pabulum  merely,  but  to  an  innate  lack  of  trophic  energy 
in  the  neurine  elements — a  general  failure  of  nutrition.  It 
manifests  itself  in  brain  sections  by  thin  cortical  matter, 
many  enlarged  perivascular  canals,  and  dilated  ventricles. 
The  curious  way  in  which  the  cerebral  envelopes  and  packing 
elements  seem  to  make  an  effort  to  expand  and  compensate 
in  bulk  for  the  shrinking  brain  is,  I  suppose,  partly  connected 
with  the  physical  conditions  of  the  closed  box  within  the 
cranium,  inaccessible  to  the  atmospheric  pressure  except 
through  the  blood-vessel  openings  and  the  foramen  magnum  ; 
and  partly  owing,  no  doubt,  to  the  congestion  of  the  whole  of 
the  tissues  supplied  by  the  carotid  arteries  and  their  branches 
that  accompanies  the  paroxysms  of  maniacal  excitement. 
From  whatever  cause,  when  the  brain  is  most  atrophied  we 
are  most  apt  to  have  thickenings  of  the  skull-cap,  often 
taking  the  form  of  successive  layerings  of  bone  over  the 
inner  table  where  it  covers  the  vertex,  and  especially  over 
the  anterior  lobes,  where  the  atrophy  is  usually  most  marked. 
The  dura  mater  is  commonly  thickened,  and  usually  adheres 
morbidly  to  the  skull-cap.  The  pia  arachnoid  is  thick  and 
fibrous,  and  the  cerebro-spinal  fluid  superabundant,  turbid, 
and  full  of  microscopic  debris. 

There  were  recent  apoplexies  of  such  a  size  as  to  be  seen 
by  the  naked  eye  in  only  five  cases.  Microscopic  apoplexies 
within  the  pia  mater,  in  the  tissues  and  round  the  softenings. 


644  SENILE   INSANITY. 

and  in  the  perivascular  canals,  are  mucli  more  frequent.  In 
fact,  tliere  are  few  cases  of  acute  senile  maniacal  excitement 
where  such  apoplexies  cannot  be  found  in  those  positions. 
But  among  all  those  cases  of  softening  it  seems  marvellous 
that  there  were  not  more  cases  of  apoplexy.  Given  vessels 
with  diseased,  weak,  and  inelastic  coats,  given  atrophy,  and 
softening  of  the  brain,  the  place  of  the  solid  tissue  being 
taken  by  mere  liquids  and  spots  of  softening,  and  add  to 
these  conditions  maniacal  attacks  implying  intense  vascular 
congestion,  one  would  think  that  large  apoplexies  must  occur 
in  every  case  from  the  want  of  support  to  the  diseased  vessels. 
Yet  we  have  seen  this  was  seldom  the  case.  The  existence  of 
small  apoplexies  probably  explains  the  occurrence  of  transient 
attacks  of  hemiplegia,  as  in  a  very  interesting  senile  case  in 
this  Asylum  reported  by  Dr  J.  J.  Brown,^  where  the  whole  of 
the  pia  mater  was  full  of  miliary  aneurisms,  and  most  of  the 
convolutions  filled  with  pin-point  apoplexies.  Such  cases,  as 
well  as  the  cases  with  Hmited  softenings,  bring  senile  insanity 
into  close  relationship  pathologically  with  paralytic  insanity, 
with  which  it  has  many  common  features.  They  are  the  two 
clinical  forms  of  insanity  most  allied.  Senile  insanity  often 
becomes  paralytic  insanity.  Paralytic  insanity  commonly 
occurs  in  old  people,  and  always  has  many  of  the  mental 
symptoms  of  senile  insanity. 

There  was  distinct  meningitis  in  three  cases,  one  of  which 
was  the  case  of  L.  E.,  with  "pachymeningitis  hsemorrhagica 
interna,"  referred  to  on  page  634.  Of  the  other  organs  of 
the  body,  the  heart  was  found  most  frequently  affected, 
there  being  marked  cardiac  disease  in  ten  cases.  The  lungs 
came  next,  with  bronchitis  and  broncho-pneumonia  in  nine 
cases  j  and  next  the  kidneys  in  two  cases.  In  many  of  the 
patients  several  of  the  above  morbid  conditions  were  com- 
bined. 

With  regard  to  the  microscopic  appearances  in  senile  brains, 
I  must  refer  to  the  careful  and  correct  descriptions  and  draAv- 
^  Journal  of  Mental  Science,  July  1877. 


SENILE  INSANITY.  645 

ings  of  Dr  Major  ^  and  Dr  Bevan  Lewis,^  and  to  Plate  II. 
fig.  5,  and  Plate  XV,  fig.  9.  Lewis  describes  and  figures 
the  proliferation  of  the  connective  tissue,  the  abundant 
scavenger  cells,  the  fatty  degenerations,  and  the  disintegra- 
tions found  by  him  in  the  brain  in  senile  insanity.  It  is 
very  striking  to  find  so  many  microscopic  lesions  common  to 
senile  insanity,  and  to  the  forms  occurring  earlier  in  life  such 
as  general  paralysis  and  alcoholism.  We  have  all  been  able 
to  confirm  those  observations,  and  perhaps  to  see  some  special 
points  in  addition.  The  various  stages  in  the  degeneration  of 
the  large  cells,  the  atrophy  of  the  smaller  cells  and  nuclei 
(see  Plate  XIII.  figs.  2  to  6),  the  enlargement  of  the  vascular 
canals,  and  the  d6bris  of  granules  and  haematin  crystals, 
were  all  well  described  by  Dr  Major.  I  have  met  with  such 
general  atrophy  as  is  represented  in  Plate  II.  fig.  5,  in  several 
cases  where  the  nerve-cells  and  fibres  were  gradually  disappear- 
ing, leaving  only  an  irregular  loose  reticulation  of  cell  walls, 
neuroglia,  and  atrophied  vessels. 

The  weak  point  in  the  pathology  of  senile  insanity  is,  that 
we  have  no  means  of  comparing  those  lesions  and  changes 
I  have  described  with  the  appearances  of  the  brains  of  old 
persons  who  were  not  insane.  Beyond  a  doubt  some  of  them, 
both  naked  eye  and  microscopic,  are  present  in  persons  whose 
mental  condition  never  got  beyond  normal  senility  ;  but  there 
is  less  doubt  that  in  the  brains  of  fifty -two  persons  from  the 
average  population  over  sixty,  there  would  not  have  been 
found  so  many  softenings  and  atrophies,  &c.  What  we  have 
to  ask  ourselves,  in  order  to  form  anything  like  a  proper 
conception  of  these  cases  of  senile  insanity,  is, — What  was 
the  relationship  between  the  purely  dynamical  phenomena  of 
morbid  mental  exaltation  or  depression,  loss  of  memory,  and 
constant  purposeless  motor  excitement,  during  hfe,  and  the 
tissue  changes  of  the  atrophied  convolutions,  the  degenerated 
cells,  the  diseased  vascular  system,  and  the  starved  areas  of 

^   West  Riding  Reports,  vol,  iv.  p.  223  ;  and  ibid.   vol.  v,  p.  161. 
2  Op.  cit.,  Plate  XV.  p.  518, 


646  SENILE  INSANITY. 

brain  found  after  death  ?  Did  these  pathological  changes,  when 
they  advanced  to  a  certain  point,  simply  allow  old  hereditary 
convolutional  weaknesses  to  come  out  that  had  been  so  slight, 
that  by  nothing  but  slow  death  of  brain  tissue  could  they 
have  become  actualities  instead  of  mere  potentialities?  Or 
had  the  advancing  brain  degeneration  simply  weakened  and 
destroyed  all  the  higher  inhibitory  faculties  and  "  centres  "in 
the  brain  ?  Is  the  constant  motor  restlessness  referable  to 
the  progress  of  the  manifest  changes  in  the  larger  "motor" 
cells  of  the  convolutions,  or  to  vaso-motor  paralysis  causing 
congestion?  Is  the  loss  of  memory  a  mere  paralysis  of  the 
power  of  attention  and  mental  concentration  on  sense  im- 
pressions— a  result  of  the  loss  of  inhibitory  power,  in  fact  ? 
Or  is  it,  in  addition,  an  absolute  paralysis  of  receptive  capacity 
on  the  part  of  the  cells  in  the  convolutions,  the  impressions 
from  the  senses  being  "  Avrit  in  water  "  ?  Or  do  the  impres- 
sions not  reach  the  convolutions  through  degeneration  of  the 
white  conducting  fibres  ?  What  Hght  does  the  whole  known 
pathology  throw  on  the  constant  connection  of  the  mental 
and  motor  symptoms  ? 

Treatment. — How  can  senile  insanity  best  be  treated  and 
managed?  I  can  only  lay  down  the  principles  that  I  have 
found  useful,  and  can  scarcely  enter  into  the  details  of 
individual  cases  or  requirements.  The  thing  of  first  import- 
ance is  undoubtedly  to  get  a  good  nurse, — a  responsible, 
skilled,  patient,  experienced  person.  "Women  make  by  far 
the  best  nurses  for  old  people  of  either  sex,  but  for  male 
patients  they  are  sometimes  not  physically  strong  enough. 
After  a  good  nurse — and  a  daughter  or  relative  will  sometimes 
make  the  best  of  all — comes  the  routine  of  management,  diet, 
exercise,  and  regimen.  Excitement,  and  new  things  or  ways, 
or  places  or  persons,  should  be  avoided.  Old  people  take 
best  with  what  they  have  been  accustomed  to.  Warmth  by 
night  and  day  is  most  important,  combined  with  airiness  of 
the  apartments.  The  clothing  should  be  warm  by  night  as 
well  as  by  day.     Cold  aggravates  excitement  and  causes  dirty 


SENILE   INSANITY.  647 

habits.  The  night  management  is  the  most  important  and 
the  most  troublesome.  It  is  better  not  to  attempt  to  keep 
the  partJents  in  bed  all  the  time  if  they  will  not  stay  there 
quietly.  Strugghng  with  them  causes  irritation  and  resistance. 
A  suite  of  airy,  not  over-furnished  apartments  downstairs  is 
the  best.  As  to  exercise  in  the  fresh  air,  it  is  most  important. 
It  makes  all  the  difference  between  being  able  to  manage 
a  case  at  home  at  all  or  to  manage  it  well  in  an  asylum. 
It  should  not  be  given  up  to  the  point  of  exhaustion,  like 
exercise  in  young  acutely  maniacal  cases.  The  walks  should 
be  short  and  often ;  and,  when  the  weather  admits,  sitting  in 
the  open  air  should  be  practised.  Senile  patients  have  a 
provoking  habit  of  sleeping  during  the  day  and  waking  at 
night.  Better  sleep  by  day  than  not  at  all.  The  diet  is  also 
very  important.  I  find  the  first  food  of  man  to  be  the  best  at 
the  opposite  end  of  life.  There  is  nothing  like  milk,  given 
warm  and  in  small  quantities  at  a  time,  and  often.  Fatten 
your  patient  and  you  will  improve  him  in  mind.  Too  much 
flesh  and  beef-tea  are  often  too  stimulating  and  indigestible ; 
cod-liver  oil  often  works  wonders,  and  so  does  maltine.  Fresh 
vegetables,  or  their  juice  in  soups,  should  always  be  given. 
All  the  soHd  food  should  be  minced  or  pounded  for  a  large 
number  of  the  cases. 

Sometimes  it  is  necessary  to  fit  up  a  special  room  in  a 
private  house  for  night  use,  without  furniture,  warmed,  and 
that  can  be  cleansed  daily.  Night  feeding  as  well  as  day 
feeding  is  often  needed.  Often  a  stomachful  of  hot  porridge 
or  bread  and  milk  will  give  a  night's  sleep  far  better  than  a 
hypnotic  medicine. 

The  purely  medical  treatment  is,  in  senile  insanity,  the  least 
important,  but  we  can  do  something  in  that  way.  My  experi- 
ence of  opium  is  unfavourable  as  a  sedative.  It  diminishes 
the  appetite,  and  often  tends  to  kill  the  patient.  But  by 
means  of  mild  doses  of  sulphonal,  used  occasionally  as  required, 
we  can  tide  over  bad  nights  comfortably,  and  we  get  the  day 
quietude  and   manageability  produced  by  the   drug.     Much 


648  SENILE   INSANITY. 

experience  enables  me  to  say  that  this  is,  on  the  whole,  by  far 
the  best  sedative  in  senile  restlessness.  I  have  enabled  rela- 
tives in  many  cases  to  keep  an  otherwise  unmanageable  case 
at  home  by  15  grain  doses  of  sulphonal.  Tonics  are  useful, 
and  iron  and  the  phosphates  often  do  much  good.  AlcohoHc 
stimulants  are  often  useful,  but  not  so  often  as  is  commonly 
supposed.  Ale  and  porter  do  very  well  sometimes.  The 
bowels  should  be  regulated  by  the  simplest  laxatives, — some 
treacle  or  syrup  given  with  the  evening  meal  of  porridge  being 
often  all  that  is  needed. 

The  great  aim,  in  most  patients,  is  to  get  into  comfortable 
normal  senihty  as  soon  and  quietly  as  possible.  In  some  the 
restlessness,  dirty  habits,  and  noise  are  so  pathological  that 
nothing  seems  to  have  any  effect  in  controlHng  or  abating  them. 
The  patient  and  liis  brain  simply  wear  themselves  out,  and 
every  one  about  him  is  thankful  when  all  is  over  without 
accident.  Few  questions  are  so  difficult  to  determine  as  the 
one  of  sending  a  very  old  person  to  an  asylum  or  not.  The 
feelings  of  every  one  go  against  it  if  there  is  a  good  home, 
dutiful  relatives,  and  sufficient  means.  The  best  way  is  to 
try  all  other  means  first.  In  good  asylums  we  give  the  poor 
suffering  from  senile  insanity  a  sort  of  treatment  that  the 
richest  often  cannot  get  at  home  for  any  price,  and  in  many 
instances  with  remarkable  success.  If,  therefore,  there  is 
poverty  and  no  conveniences  for  treatment,  one  cannot 
hesitate  about. the  course  to  adopt. 

I  am  well  aware  of  the  imperfect  view  of  the  whole  senile 
condition,  bodily  and  mental,  that  a  physician  to  an  asylum 
is  apt  to  get  from  seeing  the  very  worst  cases  only.  His 
picture  is  filled  in  with  very  black  shadows.  To  keep 
himself  right,  he  must  take  all  the  opportunities  he  has  of 
seeing  and  studying  senility  outside  of  an  asylum,  trying 
to  look  at  it  with  a  medico-psychological  and  pathological 
eye.  I  never  see  an  old  man  who  fails  to  interest  me  from 
that  point  of  view.  I  wish  physicians  in  general  practice, 
who  have  to  meet  the  smaller  emergencies  of  senihty,  would 


SENILE   INSANITY.  649 

put  their  observations  before  the  world  more  than  they  do. 
I  find  the  management  of  most  old  cases  is  regarded  without 
much  interest.  And  yet  what  a  field  of  psychological  study, 
to  be  able  to  watch  the  slow  and  gradual  process  of  mental 
dissolution  in  strong  men  and  subtile  brained  women  I 


LECTURE    XVIII. 

EAEER  AND  LESS  IMPORTANT  CLINICAL 
VARIETIES  OF  MENTAL  DISTURBANCE. 

1.  Anaemic  Insanity — 2.  Diabetic  Insanity — 3.  Insanity  from  Briglit's 
Disease — 4.  Insanity  of  Oxaluria  and  Phosphaturia — 5.  The  Insanity 
of  Cyanosis  from  Bronchitis,  Cardiac  Disease,  and  Asthma — 6.  Meta- 
static Insanity — 7.  Post-Febrile  Insanity — 8.  Influenza  and  its 
Mental  Concomitants — 9,  Insanity  from  Deprivation  of  the  Senses — 
10.  The  Insanity  of  Myxcedema — 11.  The  Insanity  of  Exophthalmic 
Goitre — 12.  The  Delirium  of  Young  Children — 13.  Insanity  of  Lead 
Poisoning — 14.  Post-Connubial  Insanity — 15.  The  Pseudo-Insanity 
of  Somnambulism — 16.  Insanity  following  Surgical  Operations. 

In  addition  to  the  more  common  clinical  varieties  of  mental 
disease,  there  are  a  great  number  of  others  rarer,  but  of  much 
interest  and  instructiveness.  Most  of  them  are  etiological 
varieties,  but  there  are  some  forms  where  the  mental  affection 
must  be  considered  an  essential  part  of  the  disease,  as  in 
myxcedema.  I  cannot  enter  fully  into  any  of  these  forms, 
but  I  shall  glance  at  some  of  those  that  have  come  under 
my  own  observation. 

1.  Anremic  Insanity. — There  are  a  few  cases  of  mental 
disease  due  to  pure  anaemia  of  the  brain  from  starvation, 
chlorosis,  or  prolonged  indigestion,  or  other  cause  of  anaemia. 
"We  had  in  the  Royal  Asylum  fifteen  of  those,  out  of  the  3145 
in  the  nine  years  1874-82.  Two-thirds  of  these  fifteen  were 
cases  of  melancholia,  and  the  rest  acute  mania.  Eighty  per 
cent,  of  them  recovered.  This  was  one  of  them  who  did  not  : 
— L.  H.,  set.  29,  of  a  quiet  and  reserved  disposition  and 
temperate   habits.     No  neurotic  heredity  known.     He   had 


DIABETIC   INSANITY.  65 1 

liad  no  work  and  little  food  for  some  time  before  coming  into 
the  Asylum,  and  had  become  weak,  anaemic,  and  run  down. 
He  then  got  restless,  sleepless,  and  unsettled,  and  next 
melancholic,  attempting  to  go  over  a  window.  Then  he 
became  acutely  maniacal.  He  was  utterly  exhausted  in 
strength,  though  acutely  maniacal  when  he  came  into  the 
Asylum.  The  maniacal  condition  alternated  with  depression, 
fearfulness,  fits  of  weeping,  and  partial  consciousness,  saying 
he  "did  not  mean  to  do  any  harm."  He  was  fed  up,  but 
he  became  demented  and  incurable  very  soon.  Most  of  the 
cases  were  mild  melanchoha,  some  of  them  having  an  element 
of  stupor,  and  those  nearly  all  recovered  within  three  months 
under  good  feeding,  fresh  air,  and  quinine  and  iron. 

2.  Diabetic  Insanity. — I  have  met  with  two  cases  in  which 
melancholia  was  associated  with  diabetes  mellitus,  and  one, 
which  was  a  case  of  melancholia,  complicated  with  diabetes 
insipidus,  passing  250  oz.  of  urine  daily.  Both  the  former 
were  also  cases  of  melancholia,  looked  at  from  a  symptomato- 
logical  point  of  view.  It  is  much  the  same  to  the  practitioner 
of  medicine  how  a  case  is  classified,  so  long  as  the  classification 
sheds  new  clinical  light  on  its  nature  and  causation.  The 
mental  condition  of  diabetic  patients  has  attracted  the 
attention  of  clinicists,  but  not  so  much  as  it  deserves. 
We,  whose  practice  lies  chiefly  in  mental  diseases,  are  often 
accused  of  seeing  nothing  but  the  mental  symptoms  of  our 
cases;  but  we  have  good  reason  to  complain  of  the  way  in 
which  the  mental  symptoms  of  ordinary  diseases  are  over- 
looked or  neglected  by  general  physicians.  The  psychology 
of  most  bodily  diseases  has  yet  to  be  written,  and  one  has 
a  faint  hope  that  the  clinical  study  of  mental  diseases  by 
students  of  medicine  may  so  familiarise  their  minds  with 
mental  symptoms  that  they  will  be  more  on  the  alert  to  look 
for  them  in  their  ordinary  practice  than  they  would  otherwise 
have  been.  When  they  are  looked  for  by  those  who  know  how 
to  observe  and  name  them  they  will  be  found.  The  whole 
lustory  of  medicine  is  one  long  tale  of  finding  things  when  they 


652  DIABETIC   INSANITY. 

were  looked  for.  Taken  in.  conjunction  with  the  peripheral 
neuritis  sometimes  seen  in  diahetes  the  melancholia  with  which 
nearly  all  the  cases  are  affected  suggests  a  toxic  auto-poisoning. 
The  first  case  was  that  of  L.  K.,  set.  59,  a  lady  who  has 
held  an  official  position,  working  hard  for  many  years. 
IS'ever  insane  before,  and  no  heredity  to  the  neuroses.  Her 
disease  showed  itself  by  mental  depression,  irritability,  in- 
capacity for  work,  a  lack  of  interest  in  anything,  and  an 
indecision  of  character  quite  foreign  to  her,  all  these  symptoms 
following  a  carbuncle  on  the  occiput.  I  was  consulted  about 
her,  and  discovered  she  had  diabetes  mellitus,  which  had 
existed  probably  for  a  year  before  the  mental  symptoms 
came  on.  She  had  no  appetite,  could  not  be  got  to  take 
enough  food,  and  what  she  did  take  seemed  to  do  her  no 
good.  She  had  the  usual  bodily  symptoms  of  diabetes — 
thirst,  frequent  micturition,  sugar  in  urine,  thinness,  and  dry 
skin.  On  account  of  the  difficulty  of  getting  her  to  take 
enough  food,  to  dress  herself,  to  go  out  to  walk,  as  well 
as  her  noise  and  restlessness  at  night,  she  was  sent  to  the 
Royal  Asylum  about  three  months  after  the  depression 
began.  The  usual  treatment  was  adopted  for  the  diabetes, 
but  Avith  no  avail.  Her  mental  energy  got  enfeebled,  until 
she  was  entirely  languid,  with  no  volitional  power.  She 
had  the  delusion  that  she  was  ruined,  and  could  not  pay 
her  debts,  and  kept  up  a  continual  wail  by  day  and  night. 
The  temperature  was  98°  in  the  morning  and  98'4°  in  the 
evening.  She  became  steadily  weaker,  and  was  giddy  when 
she  stood  up,  and  toAvards  the  end  became  sleepy  all  the 
time.  Her  urine  was  never  very  copious,  and  its  specific 
gravity  Avas  ahvays  about  1030.  She  had  a  small  ulcerated 
spot  on  her  ankle,  wliich  could  not  be  healed,  and  increased 
slowly  in  size.  She  died  rather  suddenly  six  weeks  after 
admission. 

On  post-mortem  examination  we  found  the  scalp  and  skull- 
cap of  a  yellowish  hue.  The  inner  table  of  the  skull-cap  was 
irregularly  thickened  by  bony  masses;  the  dura  mater  was 


INSANITY   OF   BRIGHT's   DISEASE.  653 

leathery ;  the  pia  mater  was  thickened  and  could  be  removed 
from  the  convolutions  with  abnormal  ease.  The  convolutions 
and  brain  generally  were  much  atrophied,  compensatory  fluid 
taking  its  place.  The  convolutions  stood  out  thin,  small, 
loosely  packed,  and  wedge-shaped.  The  fornix  and  corpus 
callosum  were  pale  and  soft.  The  lining  membranes  of  the 
ventricles  were  roughened,  with  a  trace  of  granulations. 
Sections  of  the  brain  showed  an  irregular  motthng  of  a  pink 
hue,  and  pallor  of  the  grey  substance  of  the  convolutions. 
The  whole  of  the  cerebral  substance  exhibited  a  loss  of  con- 
sistence, and  in  the  left  corpus  striatum  there  was  a  small 
locahsed  softening,  the  size  of  a  split  pea.  The  encephalon 
only  weighed  38  oz. 

Dr  Campbell  Clark  made  some  sections  of  the  medulla 
for  me,  and  they  all  show  (1)  great  looseness  of  texture, 
(2)  localised  atrophies,  (3)  abnormally  enlarged  perivascular 
canals,  (4)  degenerated  and  partially  atrophied  cells,  very 
many  of  which  have  undergone  fuscous  degeneration,  their 
processes  having  largely  disappeared,  like  the  cells  in  senile 
dementia  (Plate  XV.  fig.  9).  On  the  whole,  therefore,  the 
pathology  of  diabetic  insanity,  so  far  as  that  case  throws 
light  on  it,  seems  to  be  an  innutrition  and  general  atrophy  of 
the  brain,  especially  afi'ecting  its  convolutions.  This  form  of 
melancholia  and  its  pathology  may  be  conveniently  studied 
in  connection  with  the  neuritis  common  in  this  disease,  and 
also  with  diabetic  coma.  The  neurotic  hereditary  history  of 
diabetes— its  connection  with  insanity,  of  which  I  have  seen 
many  examples — is  of  great  interest  and  importance. 

3.  Insanity  of  Bright's  Disease. — This  is  a  variety  of  mental 
derangement,  half  delirium  and  half  mania,  which  results  from 
uraemic  poisoning.  I  have  met  with  several  cases  of  this 
disease.  Dr  "Wilks^  has  published  several  cases  of  this  kind, 
and  Sir  T.  Grainger  Stewart  says  he  has  also  seen  similar  cases. 
It  usually  occurs  in  chronic  cases  of  Bright's  disease,  with 
contracted  kidneys,  where  there  has  been  enlargement  of  the 
^  Journal  of  Mental  Scie7ice,  July  1874. 


654  INSANITY  OF   BEIGHT'S   DISEASE. 

heart  and  a  tendency  to  dropsy  for  some  time,  and  wliere  the 
central  nervous  system  has  heen  long  subjected  to  the  influence 
of  imperfectly  purified  blood.  The  symptoms  present  are 
mania  of  a  dehrious  kind,  with  extreme  restlessness,  delusions 
as  to  the  persons  round  the  patient,  an  absolute  want  of  fear 
of  jumping  through  windows  or  other  actions  that  would  kill 
or  injure.  The  symptoms  are  characterised  by  remissions, 
during  which  the  patient  is  quiet,  rather  composed  in  mind, 
and  rational,  but  very  prostrate  in  body.  One  of  my  cases 
was  L.  L.,  a  man  of  50,  with  a  family  history  of  insanity,  who 
had  once  been  much  depressed  in  mind — but  was  not  sent  to 
an  asylum — after  a  fever.  He  seems  to  have  had  heart  disease 
for  many  years,  and  to  have  had  Bright's  disease  for  at  least 
two  or  three  years  previous  to  his  admission  into  the  Asylum. 
He  had  dropsy  of  his  legs  for  some  weeks  before  the  mental 
symptoms  began.  He  was  at  first  morose  and  irritable  to  a 
morbid  degree,  and  steadily  got  worse  in  mind,  his  symptoms 
changing  to  exaltation  and  excitement,  fancying  he  could  do 
wonders,  had  absurd  schemes  for  making  money,  and  threatened 
to  murder  every  one  near  him.  On  admission  he  was  in  a 
state  of  mental  exaltation  and  excitement,  gesticulating,  say- 
ing he  had  been  married  and  had  no  children  (which  were 
delusions),  and  his  memory  quite  gone.  His  speech  was  thick 
and  indistinct,  his  tongue  coated,  his  pupils  dilated,  and  slowly 
sensitive  to  light,  the  reflex  action  of  the  cord  dulled,  and  the 
temperature  below  normal;  legs  oedematous;  his  lungs  were 
dull  at  bases,  his  heart  hypertrophied,  with  a  loud  murmur 
with  first  and  second  sounds,  urine  contained  much  albumen, 
and  a  few  tube-casts,  sp.  gr.  1020.  This  man  alternated 
between  tliis  state  of  mind  and  that  of  a  drowsy,  stupid,  but 
fairly  rational  condition  till  two  days  before  his  death,  when 
he  became  semi-comatose,  with  periods  of  dehrium.  He  only 
lived  five  weeks  after  admission,  or  about  two  months  from 
the  appearance  of  his  mental  symptoms.  This  is  a  typical 
case  of  the  disease.  No  doubt  the  mental  portions  of  his 
brain  were   the  weak  points  of   his  central   nervous   system 


INSANITY   OF   OXALURIA.  655 

from  his  hereditary  predisposition  to  insanity,  and  the  uraemic 
poison  took  effect  there  instead  of  causing  convulsions.  I 
have  had  on  two  occasions  patients  sent  to  the  Asylum  with 
uraemic  delirium  and  uraemic  coma  who  died  within  twenty- 
four  hours  of  admission,  which  shows  that  in  some  cases  this 
needs  to  he  remembered  before  a  diagnosis  of  insanity  is  made 
and  the  patient  sent  to  an  asylum. 

4.  Insanity  of  Oxaluria  and  Phospliaturia. — All  writers  on 
the  urine  have  noticed  the  hypochondriasis,  depression  of 
mind,  want  of  energy  and  originating  power,  and  the  irrita- 
bility that  so  often  go  along  with  the  presence  of  much  oxalate 
of  lime  or  phosphates  in  the  urine.  Dr  Prout^  thought  that 
the  mental  state  was  probably  the  cause  of  these  abnormal 
products  in  the  urine,  and  he  especially  mentions  "a  nervous 
state  of  the  system,  and  particularly  mental  anxiety  or  fear," 
as  causes  that  "will  frequently  produce  in  many  people  an 
excess  of  the  salt  in  the  urine."  Golding  Bird^  says  that 
"  persons  affected  with  '  oxaluria '  are  generally  remarkably 
depressed  in  spirits,  hypochondriacal,  extremely  nervous, 
painfully  susceptible  to  external  impressions,  and  in  many 
cases  labour  under  the  impression  that  they  are  about  to  fall 
victims  to  consumption."  He  says,  in  reference  to  phospha- 
turia,  that  there  are  cases  with  this  condition  characterised  by 
high  nervous  irritability,  following  injury  to  the  spine.  The 
late  Dr  Begbie  directed  special  attention  to  oxaluria  as  a  cause 
of  a  nervous  disorder  which  was  characterised  by  a  very  highly 
neurotic  condition  of  the  patient.  He  says  such  patients  are 
commonly  in  the  prime  of  life,  belong  usually  to  the  upper 
classes,  and  have  indulged  freely  in  the  good  things,  especially 
the  sweets  of  the  table.  He  says  their  sufferings  often  threaten 
their  mental  condition.  "  They  are  usually  peevish,  sensitive, 
and  irritable,  or  dull  and  desponding  and  melancholic."  His 
theory  of  the  causation  of  these  miseries  is,  that  they  "flow 
from  the  oxalic  diathesis  from  a  poison  generated  during  the 
process  of  digestion  and  assimilation,  carried  into  the  blood 
1  Piout,  p.  176,  2ud  ed.  ^  g.  Bird,  pp.  250  and  307. 


656  METASTATIC   INSANITY. 

by  the  ordinary  channels,  but  limited  in  its  pernicious  conse- 
quences by  the  busy  agency  of  the  urinary  organs  in  sepa- 
rating it  from  the  circulation,  and  discharging  it  from  the 
system."  Several  of  the  cases  he  gives  were  almost  insane, 
but  I  fancy  few  such  require  asylum  treatment.  He  shows 
that  the  nervous  symptoms  are  apparently  a  result  of  the 
oxaluria,  and  disappear  under  the  treatment  that  cures  it. 
There  is,  on  the  other  hand,  no  doubt  of  the  fact  that  oxalates 
may  be  found  in  very  great  abundance  in  the  urine  of  persons 
in  good  health.  Lehmann,  Bence  Jones,  and  Garrod,  and 
many  others  direct  special  attention  to  this  fact.  The  former, 
along  with  many  other  physicians,  thinks  that  its  appearance 
is  not  at  all  essentially  connected  with  any  special  disease 
or  train  of  symptoms.  Speaking  generally,  the  chemical 
physicians  who  have  written  on  the  urine  take  this  view, 
while  the  clinical  physicians  take  the  opposite. 

In  a  very  considerable  niimber  of  a  certain  class  of  melan- 
cholies— the  irritable  hypochondriacs — we  find  oxalates  or 
basic  phosphates  in  the  urine,  and  the  special  treatment  suit- 
able for  those  conditions  as  an  adjunct  to  the  moral  and  tonic 
treatment  of  the  melancholia  seems  certainly  to  be  useful.  I 
think  there  is  scarcely  enough  evidence  to  show  whether  this 
condition  of  the  urine  is  a  cause  or  an  effect  of  the  brain  state. 

5.  Tlie  Insanity  of  Cyanosis  from  Bronchitis,  Cardiac 
Disease,  and  Asthma. — This  is  a  form  of  delirium,  with 
confusion,  hallucinations  of  sight,  sleeplessness,  sometimes 
suicidal  impulses,  and  vague  fears.  Those  symptoms  are 
usually  worst  at  night,  and  often  end  in  mental  torpor,  pass- 
ing into  coma.  It  is  more  commonly  seen  in  persons  of 
advanced  age  than  in  young  people  (see  p,  629).  In  some 
degree  the  mental  power  is  usually  affected  in  most  old 
persons  who  have  diseases  that  prevent  the  blood  being 
properly  oxygenated.  No  doubt  an  hereditarily  Aveak  or  a 
senile  brain  suffers  more  than  a  stronger  brain  in  this  way. 

6.  Metastatic  Insanity.- — The  typical  rheumatic  insanity  is 
essentially  a  metastatic  insanity,  the  diseased  process  leaving 


POST-FEBKILE   INSANITY.  657 

the  joints,  its  normal  seat,  and  attacking  the  nervous  centres. 
I  have  seen  more  than  one  case  where  the  heahng  of  an  old 
ulcer  was  followed  by  an  attack  of  insanity,  I  have  seen 
instances  of  erysipelas  of  the  face  "striking  inwards"  and 
causing  an  attack  of  acute  mania,  I  have  often  seen  the  dis- 
appearance of  a  syphilitic  psoriasis  to  he  followed  by  melan- 
cholia, and  its  reappearance  on  the  skin  to  precede  mental 
recovery. 

7,  Post-Febrile  Insanity. — The  next  form  of  insanity  I 
shall  refer  to  is  that  called  by  Dr  Skae  post-febrile  insanity. 
The  exhaustion  of  the  vital  powers  that  is  caused  by  zymotic 
diseases  sometimes  takes  special  effect  on  the  higher  functions 
of  the  brain,  and  we  have  an  attack  of  insanity  resulting. 
The  nervous  affections  that  often  follow  fevers  in  children  are 
well  known.  These,  no  doubt,  are  precisely  analogous  to  the 
post-febrile  insanity  of  the  adult.  The  insanity  which  some- 
times followed  fevers  was  known  from  the  earliest  times,  and 
was  evidently  much  more  common  two  hundred  years  ago 
than  noAV,  but  it  was  then  ascribed,  not  to  the  exhausting 
effects  of  the  fever,  but  to  its  not  having  been  treated  with 
"  sufficient  dilution  "  and  purges  to  carry  off  the  entire  materies 
morhi,  thus  leaving  a  dangerous  element  in  the  system,  that 
was  liable  to  fly  to  the  head  and  cause  insanity.  Arnold 
thought  that  insanity  was  much  less  common  in  his  time  than 
in  Sydenham's  after  fevers  and  agues,  because  they  purged 
more  than  the  old  physicians,  and  used  the  Peruvian  bark 
more  freely.  Post-febrile  insanity  is  not  specially  confined  to 
one  kind  of  fever, 

I  went  over  the  records  of  over  a  thousand  cases  of  insanity 
that  were  sent  to  the  Carlisle  Asykim,  and  I  found  that  among 
those  there  had  been  ten  cases  of  such  post-febrile  insanity, 
four  of  which  followed  scarlet  fever,  two  small-pox,  one 
typhus,  one  typhoid,  one  intermittent,  and  in  the  tenth  case  I 
could  not  ascertain  the  exact  form.  Those  are  small  numbers 
on  which  to  base  any  conclusions  in  regard  to  a  disease,  but  I 
am  not  aware  of  any  fuller  statistics  on  the  subject.     I  think 

2  T 


658  POST-FEBRILE   INSANITY. 

those  numbers  represent  in  a  general  way  the  comparative 
frequency  of  its  occurrence  after  the  diflferent  fevers. 

Scarlatina  is  unquestionably  the  most  frequent  cause,  and 
small-pox  the  next.  It  is  said  to  follow  typhus  more  fre- 
quently than  typhoid,  and  as  intermittent  fever  is  now  very 
infrequent  in  this  country,  this  is  a  very  rare  cause  of  the 
disease. 

Whether  this  represents  the  comparative  exhausting  powers 
of  the  poisons  of  those  fevers,  on  the  brain,  or  whether  scar- 
latina stands  at  the  head  of  the  list,  from  its  greater  frequency 
or  from  its  more  common  occurrence  in  youth,  when  the  brain 
has  not  attained  its  maturity,  I  am  unable  to  say  with 
certainty.  The  form  of  insanity  that  results  after  scarlatina 
is  frequently  followed  by  dementia  which  is  incurable. 

We  might  expect  this  from  the  well-known  occurrence  of 
idiocy  and  epilepsy  in  children  after  this  disease  as  sequelae 
and  complications.  More  frequently  than  after  any  other 
fever  we  hear  the  remark — "  Such  a  person  has  never  been 
the  same  since  he  had  scarlet  fever."  On  the  whole,  I  think 
there  is  fair  ground  for  the  assumption  that  the  poison  of,  this 
disease  is  more  apt  to  leave  permanent  brain  disease  than  any 
of  the  others.  When  mental  symptoms  follow  the  disappear- 
ance of  scarlatina,  they  do  so  at  once ;  the  patient  not  having 
an  attack  of  acute  excitement  so  commonly  as  being  left  after 
the  disease  in  a  state  of  partial  dementia.  The  weakness  of 
mind  is  not  complete,  but  more  of  a  partial  imbecility,  a 
blunting  of  all  the  mental  faculties  and  affections,  with  attacks 
of  sub-acute  excitement  and  irritability.  In  two  of  my  four 
cases  there  was  deafness  along  with  the  imbecility,  .showing 
that  the  effects  of  the  disease  had  not  been  confined  to  the 
brain  convolutions,  but  had  also  affected  the  organs  or  centres 
of  special  sensation  directly,  or  through  mastoid  inflammation. 

The  form  of  insanity  that  follows  small-pox  is  of  the  same 
character  as  that  of  scarlatina,  but  is  even  more  incurable. 
That  of  typhus  and  typhoid  is  more  clearly  the  result  of  brain 
exhaustion  from  those  diseases  in  cases  where  they  have  con- 


POST-FEBRILE    INSANITY.  659 

tinned  for  a  long  time.  The  patient  seems  to  come  out  of  the 
fever,  showing  no  particular  mental  symptom  or  insanity  until 
some  weeks  afterwards,  when  he  is  attacked  with  acute  excite- 
ment, or  "gets  into  a  low  way,"  and  a  long-continued  intract- 
able depression  results.  Tuke  and  Bucknill  and  Maudsley 
say  that  the  insanity  that  follows  typhus  is  of  a  more  incurable 
kind  than  that  resulting  from  typhoid.  Sydenham  describes 
the  form  of  insanity  that  used  to  follow  ague,  and  in  his  time 
this  seems  not  to  have  been  uncommon.  He  calls  it  a  peculiar 
form  of  mania,  and  says  that  the  long  continuance  of  the  fever, 
and  its  being  of  a  quartan  type,  seemed  to  produce  the  mental 
.  symptoms  more  than  any  other  circumstances.  If  treated  by 
the  exhibition  of  strong  evacuants  it  degenerates  into  hopeless 
fatuity.  My  single  case  of  the  disease  was  that  of  a  sailor, 
who  had  regular  attacks  of  ague,  drank  hard,  lived  on  salt 
provisions  during  his  voyage,  and  on  his  arrival  had  an  acute 
maniacal  attack.  He  was  thin,  pale,  and  slightly  scorbutic. 
I  treated  him  with  abundant  diet,  malt  liquors,  fresh  air, 
quinine  and  iron,  and  a  few  draughts  of  chloral  at  bedtime, 
and  he  was  quite  well  again  in  two  months,  having  gained  20 
lbs.  in  weight  in  that  time.  In  this  case,  of  course,  there  were 
the  other  causes  of  brain  exhaustion  as  well  as  the  agiie. 

Of  my  ten  cases,  only  the  above-mentioned  patient  and  one 
of  the  scarlet  fever  patients  had  acute  symptoms  of  any  sort, 
and  they  were  the  only  ones  who  recovered.  All  the  others 
were  incurable,  six  of  them  becoming  hopelessly  demented, 
and  the  other  two  hopelessly  melancholic.  There  was  heredi- 
tary predisposition  to  insanity  in  only  three  of  the  ten  cases. 

Post-febrile  insanity  may  be  said,  therefore,  to  be  generally 
characterised  by  sub-acute  symptoms,  to  result  from  the 
brain  being  poisoned  by  zymotic  poison  and  exhausted  by 
fever,  not  to  require  a  hereditary  tendency  for  its  develop- 
ment, and  to  be  a  very  incurable  form  of  insanity  from  the 
beginning. 

I  once  met  with  a  peculiar  form  of  transient  mania  follow- 
ing an  attack  of  erysipelas  of  the  face  in  a  lady,  L.  M.,  with 


660        INFLUENZA   AND   ITS   MENTAL   KELATI0NSHIP3. 

a  strong  heredity  to  insanity,  who,  a  fortnight  before,  had 
been  attacked  vfith  erysipelas  of  the  head  and  face  of  a 
very  severe  character,  causing  much  swelling,  shutting  up  of 
the  eyes,  and  being  accompanied  by  shght  delirium.  All  the 
acute  symptoms  of  this  had  passed  off,  the  temperature  was 
down  from  104°  to  normal,  and  the  swelling  of  the  face 
was  abating,  but  still  she  could  not  open  her  eyes.  About 
three  days  before  I  saw  her  she  seemed  to  know  that  she  was 
going  out  of  her  mind,  for  she  asked  her  friends  to  keep 
her  as  long  at  home  as  possible  before  sending  her  away. 
She  then  began  to  wander  in  mind,  and  to  have  hallucina- 
tions of  sight  and  hearing,  to  mistake  identities,  and  to 
fancy  she  had  a  child.  She  would  go  on  talking  to  imagi- 
nary people,  would  especially  keep  up  long  conversations 
with  God,  would  speak  to  Him  quite  familiarly,  and  would 
fancy  she  got  an  immediate  reply.  Her  amatory  propensities 
were  exalted,  and  her  religious  feelings  and  emotions  were 
both  excited  and  perverted.  Usually  she  lay  in.  bed,  but 
was  at  times  very  violent  indeed.  Her  pulse  was  86,  and  of 
fair  strength,  and  her  temperature  98*6°.  She  slept  little. 
She  took  Hquid  food.  She  could  open  her  eyes  slightly  and 
with  difficulty,  but  seldom  did  so,  and  evidently  preferred 
to  keep  them  shut,  and  live  in  her  own  world  of  fancies. 
Her  state  much  resembled  a  "  waking  dream."  Impressions, 
however,  on  her  senses  of  hearing  and  touch  were  acutely 
felt,  and  often  were  strong  enough  to  divert  her  from  her 
unreal  behefs  and  hallucinations.  She  got  quite  well  in  a 
few  days. 

I  lately  had  a  case  of  acute  delirious  mania  of  a  very  severe 
type  following  an  attack  of  measles  in  a  young,  strong,  healthy 
lady,  L.  M.  A.  It  ran  a  typical  course,  and  she  made  a 
perfect  recovery  in  a  few  months. 

8.  Influenza  and  its  Mental  Relationships. — During  the 
years  1890-91  and  '92-94,  severe  epidemics  of  influenza 
affected  every  class  of  the  community  in  almost  every 
portion  of  the  country.     This  disease  was  universally  found 


INFLUENZA   AND   ITS   MENTAL   EELATIONSHIPS.        661 

to  affect   the   nervous   system   and   the   nerve   energy   most 
severely  wherever  else  it  localised  itself,  whether  in  the  re- 
spiratory mucous  tract,  the  lungs,  the  heart,  or  the  gastric  and 
intestinal   tract.     Its  effects  on  the  mental  functions  of  the 
brain,  both  during  the  attack  and  afterwards,  were  marked, 
and  often  specific.     Depression  of  spirits  and  loss  of  volitional 
power  were  the  two  great  symptoms  present.     I  had  a  number 
of  cases  of  melancholia  following  the  attack  sent  into  the 
Asylum,  and  I  saw  many  more  in  consultation  or  heard  of 
them  from  my   professional  brethren.     In   my  opinion  the 
microbe  or  the  poison  of  influenza  destroyed  the  cortical  energy 
to  a  much  larger  extent  than  any  of  the  continued  fevers  or 
zymotics,  nay,  its  effects  on  the  mental  condition  of  Europe 
during  the  years  of  its  prevalence  far  exceeded  in  destructive 
powers  all  those  diseases  put  together.     It  left  the  mental  and 
nervous  tone  of  Europe  lower  by  some  degrees  than  it  found 
it.     The  form  of  melancholia  was  usually  the  simple  variety, 
with  lethargy,  anaemia,  and  thinness  of  body.     Mental  dis- 
turbances may  arise  after  influenza  just  as  other  neuroses  arise, 
from  the  direct  influence  of  the  disease  on  the  brain  cortex, 
and  also  from  its  generally  weakening  and  exhaustive  effects 
after  the  acute  symptoms  have  passed  off.     Dr  Elkins  ^  found 
that  melanchoHa  was   by  far   the    most    common  variety   of 
mental  disturbance,  but  that  there  Were  no  series  nor  sequence 
of   symptoms  that  marked  out   post-influenzic  insanity  as   a 
special  type.     Some  of  the  cases  had  motor  symptoms,  simu- 
lating general  paralysis.     Mental  symptoms  short  of  insanity, 
loss  of  energy,  loss  of  power  of  application,  low  spirits,  change 
of  affective  condition,  loss  of  memory,  loss  of  interest  in  life, 
premature   senile    mental   conditions,  drink    craving,  are   all 
effects  I  have  met  with.     Fortunately  a  reasonable  number  of 
the  post-influenzic  cases  of  all  kinds  recover,  especially  if  they 
are  young.     On  the  other  hand,  there  is  no  doubt  that  the 
weakened  resistive  power  of  the  constitution  produced  by  it 
leads  to  the  development  of  senility  and  senile  tissue  degenera- 
1  Edinburgh  Hospital  Reports,  vol.  i. 


662  INSANITY   OF   .MYXEDEMA. 

tions,  phthisis,  cancer,  chronic  dyspepsia  and  many  other 
bodily  complaints.  Eest,  tonics,  nutrients,  and  especially 
change  of  air  I  found  most  useful.  I  believe  no  epidemic  of 
any  disease  on  record  has  had  such  mental  effects. 

9.  hisanity  from  Deprivation  of  the  Senses. — I  saw  a  gentle- 
man, L.  M.  B.,  some  years  ago,  who  became  melancholic  and 
suicidal  coincidently  with  his  loss  of  sight  from  cataract,  and 
who  improved  greatly  after  the  operation  for  removing  it  was 
partially  successful,  so  that  he  could  again  see  even  in  a  dim 
way  the  outer  world.  It  is  very  common  indeed  for  those 
Avho  are  deaf  to  become  quiet,  depressed,  and  irritable.  It  is 
also  common  for  such  persons  to  become  subject  to  hallucina- 
tions of  hearing,  and  so  insane  as  to  need  to  be  sent  to  asylums. 
I  have  noAv  at  the  Royal  Asylum  four  or  five  such  cases.  It 
seems  as  if  they  were  so  cut  off  from  social  intercourse  and 
the  outer  world  by  their  deafness  that  their  subjective 
experiences  became  objective  realities  to  them.  In  the  case 
of  all  men  the  senses  correct  many  "delusions." 

10.  The  Insanity  of  Myxoedema. — I  have  now  had  five  cases 
of  myxoedema  sent  to  my  care  as  patients  at  the  Asylum  who 
were  positively  insane,  and  all  the  examples  of  the  disease  I 
have  ever  seen  were  more  or  less  affected  mentally,  if  they 
Avere  not  technically  insane.  The  first  case  sent  to  the  Asylum 
was  L.  0.,  a  woman  of  38,  whose  mother  was  "nervous." 
The  patient  was  said  to  have  been  "  dropsical "  for  thirteen 
years,  which  no  doubt  was  the  time  she  had  laboured  \mder 
myxoedema.  She  had  become  lately  violent,  excited,  con- 
fused, and  full  of  changing  delusions,  with  hallucinations  of 
hearing.  On  admission  she  was  incoherent  and  sleepless. 
Under  discipline  and  nursing  she  became  more  quiet  and  slept 
better,  but  was  still  confused  and  stupid.  She  was  sent  home 
after  about  five  weeks,  her  symptoms  having  become  so  much 
better  that  she  did  not  require  asylum  treatment,  the  mania 
and  delusions  having  disappeared,  though  confusion  and 
mental  enfeeblement  remained.  The  next  case  I  had  was  the 
Asylum  plumber,  L.  Q.,  fet.  54,  who,  having  laboured  under 


INSANITY   OF    MYXCEDEMA.  663 

myxoedema  for  four  years,  suddenly  one  day  tried  to  poison 
himself,  in  a  deliberate  reasoning  way  on  account  of  a  bad 
wife.  In  consequence  of  this  and  of  his  mental  weakness  he 
was  made  a  patient  in  the  Asylum,  but  he  soon  got  into  such 
an  improved  condition  that  he  was  discharged  from  the  books 
as  a  patient,  and  remained  a  sort  of  special  indoor  pensioner 
of  ours,  and  illustration  of  myxoedema  for  the  Cliniques  and 
Medical  Societies  of  Edinburgh  till  his  death.  Mentally  he 
was  contented,  torpid,  enfeebled,  suspicious,  with  no  initiative, 
no  temper,  and  no  affection  left  for  any  one,  slow  in  his 
mental  movements  as  he  was  in  his  muscles — in  fact,  he  was 
mildly  demented.  The  third  case  was  that  of  L.  P.,  set.  37, 
on  her  admission  to  the  Asylum  in  1878.  Three  years  before 
admission  she  became  depressed,  with  hallucinations  of  smell 
— affirming  that  everything  smelt  of  gunpowder.  After  three 
years  of  depression  she  became  exalted  in  mind,  with  much 
excitement.  Her  mental  condition  was  like  that  of  a  typical 
general  paralytic,  hilarious  and  facile,  contented,  impulsive, 
Avith  delusions  of  grandeur,  thinking  her  husband  had  lately 
come  into  a  fortune.  After  eight  years  she  was  enfeebled 
in  mind,  silly  in  speech  and  conduct,  very  contented,  with  a 
thick,  slow  articulation,  expressionless  puffy  face,  with  no 
affection  and  no  keen  desires,  and  lived  at  home,  but  took  a 
drive  to  see  me  sometimes  to  ask  for  payment  for  the  work 
she  did  in  the  Asylum,  leaving  me  to  pay  the  cab.  The  fourth 
and  fifth  cases  were  also  of  this  kind,  but  made  such  a  partial 
recovery  that  they  were  able  to  live  at  home  after  a  time. 

From  the  first  patient  described  by  Sir  William  Gull  ^  in 
1873  on  to  the  latest  clinical  case  of  myxoedema  put  on  record, 
mental  symptoms  have  been  described  along  with  the  well- 
known  bodily  symptoms  of  the  disease.  Though  the  etiology 
is  here  so  definite,  yet  there  are  great  varieties  in  the  mental 
symptoms  produced  by  it.  They  all  have  slow  voluntary 
movements,  a  lowered  vaso-motor  tone,  the  reaction  time, 
mental  and  bodily,  is  prolonged.  Most  of  them  have  loss  of 
^  Clin.  Society's  Transactions,  vol.  vii.,  1874. 


664  INSANITY   OF   EXOPHTHALMIC    GOITRE. 

memory,  depression,  irritability,  delusions  of  suspicion,  loss 
of  energising,  diminished  attention  and  affective  faculty  and 
impaired  volition.  In  a  few  cases  there  were  maniacal  out- 
bursts and  some  enfeeblement  and  much  hebetude.  I  have 
now  had  three  cases  completely  cured  mentally  by  thyroid 
treatment  under  my  care,  two  of  them  being  of  several 
years'  standing,  and  one  that  I  was  so  fortunate  as  to  diagnose 
within  three  months  of  the  onset  of  the  disease.  It  ia  better 
to  make  the  treatment  slow  and  a  little  prolonged  on  account 
of  the  cardiac  and  general  depression  that  results  from  too 
rapid  cure.  The  contrast  between  the  disturbed,  stupid,  inert 
subject  of  myxoedematous  insanity,  and  the  active,  intelligent, 
bright  and  alert  person  who  is  seen  after  two  or  three  months' 
treatment  is  most  dramatic. 

11.  Insanittj  associated  until  Exophtlialmic  Goitre. — I  lately 
had  the  following  very  interesting  case,  which  has  been  more 
fully  reported  by  Dr  Carlyle  Johnstone,^  the  assistant  physician 
who  was  in  charge  of  it  : — 

L.  S.,  admitted  into  the  Eoyal  Edinburgh  Asylum  on  the 
26th  November  1881,  set.  32.  She  was  a  working  man's  wife, 
of  active  steady  habits  and  cheerful  disposition,  and  the 
mother  of  three  children.  For  the  last  three  years  she  had 
been  gradually  losing  flesh  and  strength,  and  had  latterly 
been  treated  for  goitre.  A  few  days  before  her  admission 
she  suddenly  began  to  express  delusions,  and  soon  became 
intensely  excited.  When  brought  to  the  Asylum  she  was 
in  a  condition  of  acute  excitement,  writhing,  struggling,  and 
violently  resisting  all  attempts  at  interference ;  talking 
incessantly,  and  incoherently  using  profane  and  obscene 
expressions,  and  displaying  many  vague  and  fleeting  delusions. 
In  some  respects  her  excitement  was  hysterical  in  its  character. 
She  was  very  emaciated,  and  her  physical  condition  generally 
was  very  weak.  She  presented  the  ordinary  signs  of  exoph- 
thalmic goitre — prominent  eyeballs,  cardiac  disorder,  and 
enlargement  of  the  thyroid  gland.  There  was  slight  eleva- 
^  Journal  of  Mental  Science,  January  1884. 


INSANITY   OF   EXOPHTHALMIC   GOITRE.  665 

tion  of  the  temperature,  with  a  rapid,  irregular,  and  feeble 
pulse. 

The  maniacal  condition  persisted,  with  frequent  remissions 
and  exacerbations,  for  about  a  coiiple  of  months,  and  her 
general  health  remained  wretchedly  poor.  She  was  ordered 
tonics  and  the  bromide  of  iron  continuously.  A  gradual  im- 
provement was  then  observed  in  the  mental  symptoms,  and 
the  relapses  became  less  frequent  and  less  serious.  Five 
months  after  her  admission  she  was  able  to  employ  herself 
usefully  in  the  female  infirmary,  and  as  her  convalescence 
appeared  to  become  established  she  settled  down  into  a  steady 
house-worker,  and  behaved,  except  for  occasional  hysterical 
outbursts,  in  a  sober,  rational,  and  tolerably  cheerful  manner. 
With  the  abatement  of  the  excitement  the  state  of  nutrition 
became  greatly  improved — the  increase  in  body-weight  being 
very  rapid.  There  was  little  alteration,  however,  in  the 
signs  of  exophthalmic  goitre,  and  during  her  residence  the 
patient  only  menstruated  once.  In  addition  to  these  adverse 
symptoms,  nervous  phenomena  of  a  very  grave  nature  began 
to  make  their  appearance  between  three  and  four  months 
after  admission.  These  began  with  fainting  seizures,  followed 
by  a  feeling  of  numbness  in  the  left  arm,  which,  in  subsequent 
attacks,  extended  to  the  whole  left  side.  Gradually  the 
power  of  the  left  limbs  was  entirely  lost,  and  the  sense  of 
touch  disappeared  from  the  whole  of  the  left  side,  while  the 
sense  of  pain  was  increased.  The  left  eyeball  became  more 
prominent  than  the  right,  violent  headache  set  in,  and  patient 
began  to  vomit  persistently.  She  died  on  the  19th  N'ovember 
1882,  about  twelve  months  after  admission. 

The  Autopsy  was  performed  thirty-six  hours  after  death. 
The  calvarium,  dura  mater,  and  pia  mater  were  con- 
siderably injected.  There  was  great  hypersemia  of  the  left 
hemisphere,  but  in  consistence  and  other  respects  that  portion 
of  the  brain  was  tolerably  healthy.  The  right  hemisphere 
was  very  extensively  diseased.  Over  the  whole  of  the 
superior  and  lateral  aspects  the  pia  mater  was  more  or  less 


666  DELIRIUM   OF   YOUNG    CHILDREN. 

firmly  adherent,  dragging  with  it  on  removal,  in  several  places, 
the  whole  depth  of  the  cortical  matter.  The  white  matter 
was  pink  and  mottled,  and  the  cortical  matter  universally 
soft  and  red,  and  in  many  places  quite  disorganised. 

The  optic  nerves  and  tracts  presented  no  abnormahty ;  the 
cellulo-adipose  tissue  in  the  orbits  was  increased  in  quantity ; 
the  thyroid  gland  was  much  enlarged;  there  was  a  large 
thymus  gland ;  the  heart  was  slightly  hypertropliied ;  the 
other  organs  were  tolerably  healthy. 

This  case  suggests  several  questions.  If  the  extensive  disease 
of  the  grey  matter  of  the  convolutions  existed  all  the  time,  how 
was  she  so  sane  mentally  for  a  portion  of  it  1  Was  the  origin 
of  the  case  a  cortical  one?  What  was  the  relationship 
between  the  exophthalmos,  the  goitre,  and  the  brain  disease  1 
In  such  a  case  should  we  not  now  excise  part  of  the  thyroid  1 
I  have  met  with  several  cases  of  mild  mental  symptoms  in  this 
disease,  mainly  depression,  lassitude,  irritability,  and  want  of 
power  to  do  ordinary  work,  and  one  case  of  marked  moral 
perversion  with  dipsomania. 

12.  The  Delirium  of  Young  Children. — Few  mothers  of 
large  families  but  have  had  experience  of  the  dehrium  of 
young  children.  Some  children  are  much  more  subject  to  it 
than  others.  Some  children,  in  fact,  never  have  an  increase 
of  temperature  over  9 9 '5°  Avithout  being  delirious  at  night. 
In  most  cases  it  is  a  pure  delirium  without  consciousness, 
attention,  or  memory,  but  in  some  instances  there  are  fright- 
ful hallucinations ;  in  others  an  excited  melanchoha  of  short 
duration,  with  violent  screaming,  tearless  weeping,  and  all 
the  usual  signs  of  mental  depression,  this  being  very  common 
after  severe  injuries  and  surgical  operations.  I  have  seen  a 
child  of  six  have  a  regular  attack  of  melanchoha  of  thi-s  char- 
acter lasting  for  a  few  days.  The  bromides  and  cold  to  the 
head  Avith  hot  baths  are,  no  doubt,  the  best  treatment,  with 
non-stimulating  nutrients  like  milk,  and  febrifuges  and  diapho- 
retics. The  delirium  of  children  is  determined  by  their  neurotic 
heredity.     Its  great  value  is  to  show  the  quality  of  the  brain 


PSEUDO-INSANITY   OF  SOMNAMBULISM.  667 

at  early  periods  of  life.  In  my  experience  the  same  children 
who  suffer  from  delirium  during  childhood  at  temperatures  not 
high  are  those  subject  to  "  night  terrors,"  to  chorea,  to  epilepsy, 
to  hysteria,  and  even  to  adolescent  insanity  in  later  ages. 

13.  The  Insanity  of  Lead  Poisoning. — This  is  a  variety  of 
mental  disease  which  Drs  Eayner,  Savage,  A.  Eobertson,  and 
Atkins  have  lately  ^  directed  attention  to.  Though  diseases 
of  the  nervous  system  from  lead  poisoning  have  been  long 
known  to  medicine,  I  have  only  seen  one  or  two  cases,  and 
those  not  well  marked,  and  they  were  complicated  with  al- 
coholism. All  the  cases  have  motor  symptoms,  either  con- 
vulsions, or  paralysis,  or  muscular  tremblings.  The  mental 
symptoms  are  most  various,  from  coma  down  to  slight  lassi- 
tude ;  but  hallucinations,  morbid  elevation,  maniacal  attacks, 
delusions  of  persecution,  are  the  chief  symptoms. 

14.  Post-Connubial  Insanity. — I  lately  had  a  patient,  L.  E., 
who  became  melancholic,  suicidal,  and  very  stupid  three  days 
after  his  marriage.  He  soon  got  well.  This  has  not  unfre- 
quently  been  observed.  The  mental  excitement  of  marriage 
culminating  in  an  excess  of  sexual  excitation,  is  liable  to  upset 
the  convolutional  stability  in  certain  persons  predisposed  to 
mental  disease.  In  my  experience  it  has  been  a  curable  and 
not  a  prolonged  form  of  insanity.  Some  brains  are  so  liable 
to  be  upset  in  their  mental  working,  that  it  is  no  wonder 
the  intensest  known  mental  and  physical  excitement  produces 
this  effect,  just  as  other  brains  are  upset  in  their  motor  stability 
in  like  circumstances,  and  an  epileptic  fit  occurs  on  each 
occasion  of  intercourse. 

15.  The  Pseudo-Insanity  of  Somnamlndism. — One  cannot 
admit  that  the  actual  state  of  somnambulism  is  a  form  of 
mental  disease  in  any  i^Mt^  or  sHentific  sense,  for  the  patient 
is  necessarily  asleep.  it  is  often  very  closely 
allied  to  mental  disease  ana  .  -epsy,  and  I  have  ascer- 
tained that  some  of  my  insane  patients  had  been  sleep-walkers 
during  the  period  of  adolescence.     Most  bad  and  confirmed 

'^  Journal  of  Mental  Science,  ^\\\y  1%^0. 


C68         INSANITY    FOLLOWING   SURGICAL   OPERATIONS. 

sleep-walkers  have  a  neurotic  heredity,  and  a  nervous  tempera- 
ment, or  both,  though  it  is  fortunately  quite  certain  that  few 
of  them  ever  become  insane.  Acts  of  violence,  homicide,  and 
suicide  may  be  done  in  a  state  of  somnambulism,  I  saw  in 
the  Edinburgh  prison  a  man  named  Simon  Eraser,  whose 
heredity  was  highly  neurotic,  who  had  been  an  aggravated 
sleep-walker  all  his  life,  who  during  his  somnambulism  had 
vivid  conceptions,  hallucinations,  and  illusions,  and  who  in 
that  condition  did  all  sorts  of  purposive  acts  in  accordance 
with  those  false  beliefs.  He  remembered  his  somnambulistic 
impressions  in  a  vague  way  after  he  awoke.  He  was  most 
difficult  to  awake.  He  once  went  up  to  his  neck  in  the  sea  in 
N'orway,  and  did  not  awake.  At  last,  one  night  he  got  up, 
and  while  in  a  state  of  somnambulism,  imagining  he  saw  a 
white  animal  in  the  room,  he  seized  it  and  dashed  it  against 
the  wall.  This  turned  out  to  be  his  child,  whom  he  thus 
killed  on  the  spot.^  He  was  passionately  fond  of  the  child, 
and  had  played  with  it  the  last  thing  before  it  had  gone  to 
sleep.  The  question  is — What  should  be  done  with  such  a 
man  to  protect  himself  and  others,  he  being  perfectly  sane 
when  awake?  Neither  the  lunacy  nor  the  criminal  laws  at 
present  make  any  provision  for  the  treatment  of  such  a  state 
and  its  consequences,  and  Eraser  was  accordingly  handed  over 
to  his  friends,  with  instructions  to  lock  his  door  from  the 
outside  every  night. 

16.  Insanity  folloiving  Surgical  Operations. — In  addition  to 
the  foregoing  forms  of  mental  disease,  I  have  seen  several 
cases  of  sudden  melancholia  occurring  after  surgical  opera- 
tions,— several  of  them  having  occurred  after  cystotomy, 
one  after  removal  of  the  breast,  and  one  after  amputation  of 
the  leg.  In  most  of  the  cases  iodoform  had  been  used  as  a 
dressing,  and  the  question  arises  whether  poisoning  by  that 
substance  did  not  originate  the  delirium  which  they  all 
suffered  from.     All  recovered  but  one,  Avho  died. 

1  Dr  Yellowlees  has  given  a  full  account  of  this  case  and  the  trial  in 
the  Journal  of  Mental  Science,  vol.  xxiv.  p.  451. 


LECTURE   XIX. 

THE  MEDICO-LEGAL  AND  MEDICO-SOCIAL 
DUTIES  OF  MEDICAL  MEN  IN  RELATION  TO 
MENTAL  DISEASES. 

1.  Taking  the  responsibility  of  advising  the  restriction  of  liberty,  and 
placing  cases  under  the  care  of  attendants  at  home.     2.  Signing 
Medical   Certificates   of  Insanity,    in   order   to    place   patients   in 
Asylums,  and  under  care  in  private  houses  ;  never  act  without  full 
consideration  :  (a)  Is  the  patient  insane  ?  (6)  if  so,  is  he  "a  proper 
person  to  be  detained  under  care  and  treatment "  ?  (c)  why  should  he 
be  placed  in  an  Asylum  or  sent  from  home  ?  (d)  is  there  any  legal 
risk  to  those  who  take  the  steps  for  Asylum  treatment  ?  (c)  fill  up 
the  first  part  of  the  Certificate  up   to    "Facts"   most   carefully, 
remembering  it  is  to  go  before  lawyers  ;  (/)  "facts  indicating  insanity 
observed  by  myself"  the  most  important  part  of  Certificate  ;  delu- 
sions most  important ;  appearance  and  manner  of  patient ;  expres- 
sion of  face  ;  incoherence  ;  want  of  memory  ;  change  from  natural 
condition  ;  suicidal  or  homicidal  expressions  ;  taciturnity  ;  inability 
to  answer  simple  questions,  and  negative  symptoms  ;  quote  words 
used  ;   put  no  redundancies  ;   cumulative  facts  ;    {g)    "  Facts  com- 
municated by  others,"  corroborative  ;  attempts  at  suicide  ;  assaults  ; 
paroxysmal  aggravations  ;  conduct  when  not  watched  ;  {h)  Get  the 
cue  to  delusions,  &c.,  from  others  before  you  see  patient ;  {i)  Necessity 
for  tact ;  sometimes  a  little  stratagem  ;   cunning  and  reticence  of 
patients  ;  {k)  Can't  keep   patients  in  private  houses  "  for  profit " 
without  certificate    in   England,    or   notice   to    Commissioners   in 
Scotland.     3.  Giving    Certificates   of    sanity  ;   need    for   care   and 
caution.     4.   Giving  Certificates  as  to  the  appointment  of  a  Curator 
Bonis  in  Scotland,  and  making  affidavits  and  giving  evidence  before 
a  Master  in  Lunacy  in  England  or  a  Judge  in  Ireland  when  a  lunacy 
inquiry  is  held  by  him.    5.  Giving  evidence  as  to  the  existence  of  men- 
tal disease  or  not  in  criminal  cases,  to  enable  the  law  to  fix  or  absolve 
from  responsibility,  before  higher  and  lower  courts,  and  as  adviser  to 
Procurator-Fiscal  in  Scotland.     Crimes  most  commonly  committed 
in  Mania ;  epileptic,  alcoholic,  puerperal,  and  simple — Melancholia: 


670    DUTIES   OF    MEDICAL   MEN    IN    MENTAL   DISEASES. 

Excited  and  delusional — Dementia  :  Impulsive  violence — Iinjndsire 
Insanity :  Homicidal,  Kleptomania,  Pyromania,  Animal  Impulse  ; 
complications  of  Insanity  with  Drunkenness  ;  somnambulism  and 
allied  states ;  divergence  of  Medical  andLegal  views — Successive  Legal 
Views  :  Wild  beast  tlieory  (Tracey) ;  knowledge  of  right  and  wrong 
(Mansfield)  ;  knowledge  of  right  and  wrong  as  to  the  act  (Twelve 
Judges)  ;  delusional  test  (Denman)  ;  habit  and  repute  (Moncrietf)  ; 
power  of  control  (New  Criminal  Code,  Stephen) ;  difficulty  of  cases 
on  the  Borderland  ;  necessity  for  caution,  full  knowledge  of  all  the 
facts,  and  strict  impartiality.  6.  Giving  evidence  as  to  civil  capa- 
city ;  management  of  property,  making  wills,  contracting  marriage, 
&c.  ;  great  caution  here  ;  get  facts  on  both  sides  of  the  question  ; 
don't  promise  to  give  evidence  till  you  have  got  all  the  facts — Mode 
of  life  ;  "habit  and  repute  ;  "  eccentricity  ;  youthful  extravagances  ; 
wide  views  of  the  law  on  this  matter  ;  Scotch  provision  of  Curator 
5o?ws  without  deprivation  of  personal  liberty —  Will-making:  {a)  Is  he 
free  from  influence  of  drink  or  drugs  ?  (&)  does  he  understand  the  nature 
of  the  act  he  is  doing,  and  the  effect  of  the  document  ?  (c)  can  he  state 
his  reasons  for  making  a  will  ?  (cl)  is  the  disposition  of  the  property  a 
natural  one,  and  if  not,  why  ?  (e)  is  it  not  influenced  by  insane  delusion 
or  insane  state  of  mind  ?  (/)  is  there  no  facility  with  undue  influence 
being  exerted  ?  (g)  can  he  tell  twice  over  the  disposition  he  wishes  to 
make  ?  (h)  can  he  tell  his  relations  and  their  claims  on  him  ?  (i)  can  he 
tell  the  amount  of  his  property  ?  {j)  is  there  any  brain  disease  ?  don't 
let  a  good  motive  sanction  a  bad  will,  7.  Detecting  Feigned 
Insanity  :  No  general  rule  ;  are  the  symptoms  those  of  anj'^  known 
type  of  insanity  ?  is  there  any  motive  '\ — Watch  the  patient  when  he 
thinks  he  is  unobserved  ;  commonly  overdoes  his  part  ;  power  of 
endurance  ;  sleep  ;  sensibility  ;  sudden  shocks,  shower  bath,  electric 
battery,  &c.  ;  hysteria  ;  effect  of  drugs  ;  Difficulty  of  the  question. 
Was  Hamlet  mad  ?  Self-accusations  of  really  insane  people.  8.  Giv- 
ing confidential  familj'  advice  as  to  such  matters  as  engagements  to 
marry,  education,  choice  of  profession,  sudden  change  of  conduct  and 
morals,  &c.  ;  Dreadful  effect  of  helping  to  increase  the  neuroses,  the 
insanity,  and  the  idiocy  in  the  world  ;  on  the  other  hand,  Maudsley's 
opinion  as  to  genius  resulting  from  neurotic  marriages  ;  Special 
mode  of  education  sometimes  needed  for  neurotic  children. 

The  medical  profession  has  grave  medico-legal  responsibilities 
thrown  on  it  by  the  provisions  of  many  of  the  forty  enact- 
ments that  stand  on  the  Statute  Book  relating  to  the  insane. 
In  addition  to  their  statutory  duties,  judges,  lawyers,  and 
administrators  of  the  law  constantly  call  in  medical  men  to 
help  them  in  the   solution  of   questions  that  they  only  can 


DUTIES   OF   MEDICAL   MEN   IN   MENTAL   DISEASES.     671 

solve.  There  are  few  things  about  which  the  British  public 
is  more  sensitive  than  those  relating  to  the  liberty  of  the 
subjectj  to  civil  capacity,  and  to  the  control  of  property.  In 
addition  to  these  responsibilities,  there  are  most  delicate 
duties  of  a  purely  medical  and  medico-social  kind  thrown  on 
our  profession  by  the  exigencies  of  practice,  and  the  impossi- 
bility of  finding  elsewhere  so  qualified  and  wise  an  adviser 
as  the  family  doctor.  There  is  no  doubt  that  all  tiiose  duties 
should  be  done  with  much  care,  and  after  searching  inquiry 
into  facts,  and  a  grave  consideration  of  the  whole  eff'ects  of 
any  opinion  expressed  or  of  any  act  done.  A  special  know- 
ledge of  the  subject,  experience,  sound  judgment,  conscien- 
tiousness, and  caution,  are  all  quahties  requisite  in  dealing 
medico-legally  with  the  insane. 

The  chief  medico-legal  and  medico-social  duties  of  medical 
men  in  relation  to  mental  diseases  may  be  thus  classified  : — 

1.  Taking  the  responsibility  involved  in  treating  cases  at 
home,  placing  them  under  the  care  of  attendants,  advising  that 
they  should  be  put  under  a  certain  degree  of  control,  and  pre- 
vented from  transacting  business.  This,  in  doubtful  cases  and 
in  the  early  stages  of  the  disease,  is  often  a  very  serious  thing 
to  do.  The  patient  does  not  know  he  is  ill,  says  in  fact  he  is 
quite  well,  resents  as  an  insult  and  a  degradation  being  put 
under  control,  and  threatens  all  who  have  to  do  Avith  it  with 
the  most  dire  consequences.  The  only  sound  and  safe  rule 
for  the  doctor  is  to  make  it  clear  that  he  only  advises,  and 
does  not  take  any  legal  responsibility  whatever  for  the  steps 
by  which  a  patient  is  controlled.  Let  that  fall  on  a  relation 
who  has  the  legal  right  or  moral  duty  to  take  measures  for 
the  safety  of  the  patient,  and  on  no  account  be  assumed  by  the 
doctor,  to  whom  the  law  gives  no  authority  whatever  but  to  grant 
certificates.  If  the  patient  is  removed  to  lodgings  to  be  under 
treatment,  the  relatives  must  authorise  this  step.  It  need  not 
be  the  nearest  relative.  It  is  often  desirable  to  have  family 
councils  under  those  circumstances.  Especially  when  hus- 
bands or  wives  are  mentally  affected,  "  both  sides  of  the  house  " 


672     DUTIES   OF   MEDICAL   MEN   IN   MENTAL   DISEASES. 

should,  if  possible,  be  taken  into  consultation.  But  as  regards 
the  doctor  the  rule  is  clear.  Let  him  advise  but  not  act.  I 
have  even  in  some  rare  cases  refused  to  take  the  responsibility 
of  regular  attendance  and  treatment,  without  first  getting  a 
letter  of  protection  from  legal  risk.  The  attendants  in  charge 
are  the  servants  of  the  relatives,  and  under  their  orders 
technically  and  legally,  however  much  in  fact  they  may  be 
under  the  doctor's  deputed  authority. 

In  England  a  patient  can  be  treated  at  his  own  home  or 
anywhere  else,  if  not  "  for  profit,"  without  certificates  of 
lunacy,  as  long  as  his  friends  desire,  and  so  long  as  he  is  not 
badly  treated,  which  last  procedure  subjects  those  responsible 
for  it  to  very  heavy  punishment.  In  Scotland  a  patient  can 
be  treated,  with  a  view  to  cure,  anywhere  out  of  an  asylum 
for  six  months  without  formal  certificates,  if  a  medical  opinion 
to  that  effect  and  intimation  is  sent  to  the  Commissioners  in 
Lunacy.  This  is  a  most  valuable  and  common-sense  provision. 
The  time  might  very  well  have  been  extended  to  twelve 
months.  If  treated  at  home  or  anywhere  else  "without 
profit,"  and  his  treatment  impHes  control  over  his  actions, 
his  case  must  be  intimated  to  the  Commissioners  at  the  end 
of  twelve  months. 

2.  The  most  common  of  all  the  medico-legal  -duties  throicn 
on  medical  men  is  that  of  signing  the  statutory  medical  certifi- 
cates for  placing  patients  in  asylums  or  under  care  in  private 
houses.  This  is  done  for  the  proper  treatment  of  the  patient, 
and  often  for  his  safety  as  well  as  for  the  safety  of  the  public. 
The  form  of  certificate  is  fixed  by  statute,  and  no  other  form 
will  do.  The  form  is  practically  the  same  in  England,  Scot- 
land, and  Ireland,  though  the  mode  of  placing  a  patient  in 
the  asylum  is  diff"erent  in  the  three  countries.  In  England 
a  private  patient  can  be  placed  in  an  asylum  only  on  the 
"order"  of  a  magistrate  after  the  two  medical  certificates  and 
a  petition  from  a  relative  have  been  obtained ;  in  Scotland 
the  sheriff  must  sign  the  "  order,"  after  having  seen  the 
petition,  statement,  and  medical  certificates.     Pauper  patients 


DUTIES   OF   MEDICAL   MEN   IN   MENTAL   DISEASES.     673 

are  placed  in  asylums  in  England  and  Ireland  on  tlie  order  of 
a  magistrate,  who  must  see  the  patient,  and  on  one  medical 
certificate;  while  in  Scotland  pauper  patients  are  placed  in 
asylums  in  the  same  way  as  private  patients,  that  is,  on  a 
petition  and  statement  by  the  inspector  of  poor,  two  certifi- 
cates, and  a  sheriff's  order. 

As  to  the  grounds  on  which  a  British  subject  can  be  legally 
deprived  of  his  liberty  on  account  of  insanity,  the  common  law 
of  England  only  recognised  as  a  sufiicient  cause  danger  to  the 
patient  or  the  public,  and  a  recent  decision  seems  to  imply 
that  some  Judges  still  hold  that  to  be  the  law.  But  by  the 
universal  practice  of  the  country,  sanctioned  by  the  Com- 
missioners in  Lunacy,  the  recent  statutory  law  is  taken  as 
superseding  or  supplementing  the  common  law ;  and  the 
former,  without  defining  insanity,  or  prescribing  any  specific 
grounds  on  which  a  patient  may  be  detained  as  a  lunatic, 
clearly  enacts  that  "  care  and  treatment "  are  the  chief  objects 
of  his  detention,  and  his  being  dangerous  is  nowhere  made 
a  sine  qua  non.  This  being  so,  the  first  thing  a  medical  man 
with  an  insane  patient  who  needs  care  and  treatment  in  an 
asylum,  or  to  be  boarded  with  a  private  family,  has  to  do,  is 
to  make  up  his  own  mind  in  regard  to  the  definite  grounds 
on  which  the  steps  are  to  be  taken.  Having  done  so,  his 
next  business  is  to  convince  the  patient's  responsible  relatives 
of  the  necessity  for  certification.  In  doing  this  it  is  far  better 
not  to  press  them  too  strongly  at  first  if  they  do  not  see  the 
necessity  for  it.  All  that  is  necessary  is  to  explain  the  reasons 
for  your  opinion,  point  out  the  risks,  and  that  the  responsi- 
bility rests  on  them,  not  on  the  doctor.  It  may  in  some  rare 
cases  be  necessary,  before  certifying,  to  get  a  letter  from  a 
responsible  person,  protecting  the  doctor  from  risk  of  a  legal 
action.  This  is  a  risk  no  medical  man  in  signing  a  certificate 
of  lunacy  should  subject  himself  to  if  he  can  help  it.  Eecent 
English  lunacy  statutes  debar  actions  if  there  is  no  reasonable 
ground  for  imputing  to  the  doctor  want  of  good  faith  or 
reasonable  care,  a  Judge  of  the  High  Court  having  power  to 

2  u 


674  DUTIES   OF   MEDICAL   MEN   IX 

stop  proceedings  on  application,  and  the  Scotcli  law  debars 
actions  after  twelve  months  from  the  patient's  discharge  from 
the  asylum ;  but  if,  in  spite  of  this,  under  the  common  law, 
actions  can  still  be  brought  against  medical  men  for  doing  a 
statutory  duty  in  a  legal  way,  they  must  just  protect  them- 
selves by  a  letter  of  indemnification,  or  as  best  they  can.  In 
the  case  of  pauper  patients  the  chief  responsibility  undoubtedly 
rests  on  the  medical  man,  to  whom  the  reheving  officers  or 
inspectors  of  poor  must  refer  the  question  of  asylum  treat- 
ment, and  must  act  on  his  opinion,  and  he  runs  the  risk  of 
an  action  accordingly. 

In  solving  the  question  of  whether  a  patient  should  be 
certified  as  a  lunatic  or  not,  the  first  thing,  of  course,  to  ask 
oneself  is — "Is  the  patient  insane?"  And  it  is  well  to  be 
prepared  to  say  what  kind  of  insanity  he  labours  under.  To 
determine  this  question,  one  must  have  evidence  of  mental 
disease  observed  by  oneself,  but  may  also  use  any  facts  prov- 
ing it  as  ascertained  from  others  who  have  seen  the  patient. 
If  he  is  insane,  then  comes  the  further  question — "Is  he  a 
proper  person  to  be  detained  under  care  and  treatment  ? " 
Many  persons  are  insane  in  a  medical  and  even  in  a  legal 
sense,  yet  have  so  much  self-control  left,  or  their  mental 
peculiarities  are  so  slight  and  harmless,  that  they  are  not 
proper  persons  to  be  detained  under  care  and  treatment.  I 
would  say  that  the  chief  tilings  that  constitute  the  statutory 
fitness  are — danger  to  themselves  or  others ;  disturbance  of 
the  pubhc  peace  ;  inability  to  care  for  and  manage  themselves 
and  their  affairs ;  acute  mental  symptoms  of  any  kind ;  or 
amenabihty  to  curative  treatment  which  cannot  be  appHed 
without  certification.  Xo  doubt  all  sorts  of  considerations — 
social,  monetary,  and  domestic — come  in  before  determining 
the  expediency  of  certification.  One  has  to  ask  what  are  the 
reasons  for  his  removal  from  home,  how  he  will  be  likely  to 
look  on  it  after  his  recovery,  and  how  will  it  affect  him  and 
his  affairs  generally?  Then,  of  course,  it  is  proper,  having 
determined  that  he  should  be  certified,  to  ask  what  legal  risk 


RELATION   TO   MENTAL   DISEASES.  675 

there  is  to  yourself  or  to  his  relations.  I  know  an  undoubt- 
edly dangerous  lunatic  who  kept  himself  out  of  an  asylum  by 
bribing  one  member  of  his  family  by  money  gifts  to  oppose 
his  seclusion  under  all  circumstances,  and  by  threatening  any 
one  of  his  children  who  might  move  in  the  matter  with  disin- 
heritance in  his  will.  It  may  be  necessary  to  see  the  patient 
several  times  before  you  can  make  up  your  mind.  When 
those  questions  have  been  answered,  and  you  proceed  to 
certify,  then  (a)  fill  in  the  first  and  purely  formal  part  of  the 
certificate  in  all  cases  as  if  it  were  an  important  business  and 
legal  document,  looking  at  the  directions  on  the  margin. 
Our  profession  is  not  always  sufficiently  particular  about  this. 
Lawyers  look  on  this  part  as  of  much  importance.  Not  to 
designate  the  patient,  and  put  in  his  residence  at  the  proper 
place,  is,  according  to  Sir  Cresswell  Cresswell's  judgment,  to 
invalidate  the  whole  document,  and  the  English  Commissioners 
always  return  it  to  the  writer  for  correction  if  this  is  not 
done.  The  reason,  no  doubt,  is,  that  there  being  ten  thousand 
Thomas  Jones  in  the  country,  it  is  necessary  to  discriminate 
clearly  which  one  is  the  lunatic  you  are  certifying.  In 
England  and  Ireland  you  must  have  seen  the  patient  within 
a  week  of  certification,  in  Scotland  on  the  same  day. 

(b)  Then  comes  the  most  important  part  of  all,  viz.,  the 
"facts  indicating  insanity  observed  by  myself."  "Without 
these  facts  the  certificate  is  not  vaHd  at  all.  Think  of  what 
the  patient  says,  what  he  does,  and  what  he  looks  like.  By 
all  means  put  in  first  the  most  evident  and  indisputable 
insane  delusions  the  patient  labours  under,  in  as  crisp  and 
clear  a  way  as  you  can.  'No  evidence  of  insanity  is  so  satis- 
factory to  lawyers  as  insane  delusions.  Xext  to  those  in 
cogency  come  incoherence  of  speech,  or  shouting,  or  out- 
rageous conduct,  or  loss  of  memory  and  reasoning  power. 
Put  into  the  certificate  some  of  the  patient's  very  words,  if 
possible.  !N"ext  to  those  come  such  "  facts  "  as  relate  to  the 
patient's  appearance,  expression  of  face,  and  manner.  If 
you  have  known  him  before,  any  changes  from  his  normal 


676  DUTIES   OF  MEDICAL   MEN   IN 

condition  should  be  noted.  By  tlie  way,  in  putting  down 
delusions  it  is  necessary  often  to  add  to  a  statement  of  one, 
the  words  "  which  is  a  delusion."  Some  things  may  be  quite 
true,  e.g.,  "He  says  he  has  £10,000  a  year,"  and  therefore 
needs  tliis  explanation.  On  the  other  hand,  such  delusions 
as  "  Says  he  is  God  Almighty  "  do  not  need  anything  of  the 
kind.  If  any  suicidal  or  homicidal  expression  can  be  got 
hold  of,  put  it  among  the  facts,  but  usually  these  have  to 
come  under  the  "facts  communicated  by  others."  Negative 
signs,  such  as  absolute  taciturnity,  insensibility  to  impressions 
from  without,  are  good  enough  "facts."  It  is  better  to  put 
no  "facts"  that  do  not  clearly  indicate  insanity,  but  there  are 
some  cases  where  the  e^ddence  must  consist  of  lesser  things 
than  those  I  have  mentioned,  put  in  a  cumulative  way,  e.g., 
"His  manner  is  very  peculiar.  He  is  slightly  incoherent  and 
silly  in  speech.  His  memory  is  impaired  somewhat.  He 
has  no  sane  interest  in  his  affairs  or  in  his  relations  or 
belongings.  His  eye  is  vacant  in  expression.  His  whole 
conversation  gives  me  the  impression  that  he  is  unfit  to 
manage  his  affairs,"  were  really  all  the  facts  observed  by 
myself  I  could  put  down  as  the  result  of  one  interview  with 
a  person  of  mildly  enfeebled  mind.  It  is  better  to  use  facts 
observed  at  the  last  interview. 

I  could  give  instances  of  most  ridiculous  "facts"  put  into 
lunacy  certificates  by  medical  men.  "  He  is  incoherent  in  his 
appearance."  "Eyes  restless  and  wandering,  but  following 
the  usual  occupation  of  breaking  stones."  "  Says  she  is  in 
the  family  way  (she  had  a  baby  in  a  few  months)."  "  Reads 
his  Bible,  and  is  anxious  about  the  salvation  of  his  soul,"  are 
examples. 

Never  put  in  such  statements  as  these — "  He  has  no  delu- 
sions." "His  self-control  is  not  lost."  Those  are  not  un 
common,  but  they  go  to  prove  sanity,  not  insanity. 

(c)  The  "  facts  indicating  insanity  communicated  to  me 
by  others,"  that  follow,  are  very  important  as  subsidiary  and 
not  essential  points  of  the  certificate.     Among  them  you  can 


RELATION   TO    MENTAL   DISEASES.  677 

insert  descriptions  of  previous  aggravations  of  conduct  and 
speech,  of  attempts  or  threats  of  suicide,  or  danger  to  others. 
You  must  put  down  the  name  of  your  informant. 

{d)  The  signature,  residence,  and  dating  must  be  carefully 
done.  After  the  whole  certificate  is  completed,  I  advise  every 
man  to  run  it  over  carefully.  Few  men  are  so  accurate  that 
they  will  not  sometimes  omit  something. 

The  greatest  tact  is  necessary  often  to  bring  out  the  real 
condition  of  a  patient's  mind.  This  is  often  impossible,  in 
fact,  even  when  you  know  on  good  evidence  that  he  is  insane. 
Especially  is  this  the  case  when  he  thinks  you  are  a  doctor 
come  to  certify  him.  He  then  naturally  conceals  his  delu- 
sions, and  puts  his  best  foot  foremost.  Sometimes  a  little 
stratagem  is  necessary.  The  weak  are  always  cunning,  and 
it  seems  as  if  this  quahty  was  exaggerated  in  some  insane 
patients.  By  all  means  get  the  cue  to  his  delusions,  if  they 
exist,  and  as  full  a  knowledge  of  the  patient's  case  as  you  can 
before  you  see  him.  I  have  more  than  once  entirely  failed 
to  educe  facts  enough  on  which  to  found  a  certificate  in  the 
case  of  a  man  I  knew  to  be  insane  and  dangerous.  I  do  not 
consider  it  a  justifiable  thing  to  give  the  patient  drink  in 
order  to  make  him  speak  what  is  in  his  mind,  or  to  bring  out 
his  peculiarities,  though  I  have  known  it  done  more  than 
once. 

In  England  and  Scotland  patients  may  be  placed  under 
treatment  in  asylums  on  "  emergency  orders,"  given  by  a 
relative  or  friend  and  one  medical  certificate.  In  England 
they  can  be  detained  on  such  orders  for  seven  days,  and  in 
Scotland  for  three  days  without  any  magistrate's  or  sherifi''s 
order,  which  can  be  got  within  these  times. 

3.  Medical  men  have  to  give  certificates  of  sanity  as  well  as 
of  insanity  sometimes.  These  need  great  care,  much  circum- 
spection, and  considerable  inquiry  into  the  facts  of  a  man's 
life  and  behaviour.  I  have  on  two  occasions  had  insane 
patients  leave  the  Asylum  and  return  to  me  with  certificates 
of  sanity  got  from  incautious  doctors.     In  one  case  the  patient 


678  DUTIES   OF   MEDICAL   MEN   IN 

produced  and  kept  it  as  a  good  joke.  It  would  be  an 
awkward  thing  for  the  certifier  if,  after  getting  such  a  certifi- 
cate, the  patient  went  and  made  a  will,  or  killed  himself.  In 
a  way,  a  certificate  of  sanity  needs  more  inquiry  before  it  is 
given  than  a  certificate  of  insanity.  Certificates  of  sanity  are 
needed  to  set  aside  a  Curator  Bonis,  or  committees  of  the 
person  and  estate  in  England,  and  often  also  before  a  man 
is  allowed  to  resume  employments  and  pubHc  appointments. 

4.  Management  of  Proj)erty  ;  Civil  Rights — When  a  man  is 
ipso  facto  deprived  of  his  civil  rights  and  the  control  of  his 
yrojperty  hy  heing  imt  into  a  lunatic  asylum,  or  is  so  insane  or 
weak-minded  that  he  cannot  properly  traTisact  business,  he  must 
have  his  property  looked  after  and  administered  for  his  benefit, 
and  a  legal  process  has  to  be  gone  through  fur  that  purpose.  In 
England  and  Ireland  affidavits  have  to  be  given,  stating  facts 
indicating  insanity,  and  especially  incapacity  to  manage  pro- 
perty, which  are  sent  to  the  Court  of  Chancery,  and  on  them, 
as  prima  facie  proof,  an  inquisition  de  lunatico  inquirendo  is 
held  by  a  Master  in  Lunacy,  sent  to  the  patient's  residence  for 
the  purpose,  at  which  medical  and  other  sworn  evidence  is 
taken.  If  the  patient  is  found  lunatic,  one  person  is  com- 
monly appointed  "committee  of  the  person,"  to  control  the 
person,  and  another  "  committee  of  the  estate,"  to  manage  the 
property,  and  no  further  certificates  are  needed  for  placing 
him  in  an  asylum.  If  the  patient  demands  it,  and  the  Court 
thinks  it  right,  a  jury  may  be  called ;  if  not,  the  ]\Iaster  sits 
alone  and  reports  his  decision  or  that  of  the  jury  to  the  Lord 
Chancellor.  This  is  a  cumbrous  and  expensive,  though  an 
efficient  and  fair  process.  If  the  property  is  small,  the  pro- 
cess is  simpler  and  cheaper.  Some  such  process  should  be 
provided  for  doubtful  and  important  cases,  but  in  ninety-nine 
out  of  a  hundred  it  is  an  unnecessary  waste  of  money  and 
judicial  talent.  The  ordinary  Scotch  process  is  far  simpler 
and  less  expensive.  Two  doctors  sign  certificates  "on  soul 
and  conscience"  of  the  man's  "insanity  or  incapacity  to 
manage  his  own  afi"airs,  or  to  give  directions  for  their  manage- 


KELATION   TO   MENTAL   DISEASES.  679 

ment,"  or  some  such  form,  and  those  are  presented  with  a 
petition  from  a  near  relation,  stating  the  amount  of  his  pro- 
perty, to  a  Judge  of  the  Court  of  Session,  who  orders  them  to 
be  served  on  the  patient  and  intimated  in  a  certain  place  in 
the  Court  for  eight  days,  after  which,  if  there  is  no  oppo- 
sition, a  Curator  Bonis  is  appointed,  who  then  manages  the 
lunatic's  property,  and  acts  for  him,  after  finding  due  caution 
for  the  proper  performance  of  his  duties.  He  has  to  present 
an  account  of  his  intromissions  to  the  Court  every  year. 
The  weak  point  of  the  Scotch  system  is,  that  usually  no 
proper  guardian  of  the  lunatic's  person  is  appointed.  The 
nearest  relative  commonly  acts  as  such.  If  the  application 
is  opposed,  the  Judge  has  power  to  investigate  the  facts  in 
almost  any  way  he  thinks  best,  through  the  Sheriff  of  the 
County,  through  an  expert,  or  by  means  of  evidence  in  open 
Court.  Occasionally  a  Curator  Dative  is  appointed  to  control 
the  person,  but  this,  with  the  process  of  "  Cognition,"  are 
cumbrous  antiquated  processes  seldom  resorted  to.  We  need 
in  Scotland  an  inexpensive  but  efficient  process,  combined 
with  the  procedure  for  the  appointment  of  the  Curator 
Bonis,  to  appoint  a  guardian  of  the  person.  Differences  of 
opinion  between  the  curator  and  the  relatives  I  have  known 
to  occur  with  us  as  to  the  disposal  of  the  patient. 

5.  Medical  men  are  often  called  on  to  give  evidence  as  to  the 
existence  or  not  of  mental  disease  in  persons  accused  of  crime, 
to  enable  the  law  to  fix  or  to  absolve  from  responsibility.  In 
Scotland  the  procurator-iiscal  usually  has  a  medical  adviser, 
with  a  view  to  determine  the  kind  of  proceedings  to  be  taken 
in  cases  where  crime,  danger,  or  disturbance  may  have  been 
the  result  of  mental  disease. 

The  forms  of  insanity  in  which  crime  is  usually  committed 
are  mania,  epileptic  insanity,  delusional  insanity,  and  alcoholic 
insanity,  and  sometimes  puerperal  insanity,  delusional  and 
homicidal  melancholia,  sometimes  dementia  and  .  congenital 
imbecility,  and  also  impulsive  insanity  where  there  are  un- 
controllable homicidal,  kleptomaniacal,  pyromaniacal,  destruc- 


680  DUTIES   OF   MEDICAL   MEN   IX 

tive,  or  animal  impulses.  Some  of  the  complications  of  mental 
disease  with  the  effects  of  drunkenness  are  often  most  puzzling 
both  to  medical  men  and  to  lawyers  "when  crime  has  resulted 
from  them.  My  experience  is,  that  crime  is  usually  com- 
mitted at  the  same  stage  of  attacks  of  insanity  that  suicides 
are  ordinarily  committed,  viz.,  in  the  incij)ient  stage.  Drunken- 
ness is  held  to  aggravate  crime,  hut  alcoholic  insanity  exempts 
from  punishment. 

There  has  always  been  a  tendency  towards  a  divergence 
of  view  between  medical  men  and  lawyers  in  regard  to  the 
amount  and  kind  of  mental  disease  that  should  exempt  from 
punishment  for  crime.  Certainly  the  law  has  gradually  come 
round  more  and  more  towards  the  medical  view, — has, 
in  fact,  recognised  the  facts  of  nature  in  mental  disease. 
Judge  Tracey  held  that,  except  a  criminal  was  irresponsible  as 
a  "  wild  beast,"  he  should  suffer  punishment.  Lord  Mansfield 
held  that  a  "knowledge  of  right  and  wrong"  was  the  test. 
The  twelve  Judges  declared  in  M'l^aughton's  case  that  a 
knowledge  of  right  and  wrong  in  relation  to  the  act  committed 
should  be  the  true  legal  test;  Lord  Denman  said  that  legal 
responsibihty  should  depend  on  the  presence  or  absence  of 
insane  delusion ;  Lord  Moncreiff  has  laid  it  down  that  a  man's 
habit  and  repute  as  to  sanity  among  his  fellow-men  who  knew 
him  well  should  determine  his  legal  responsibility  for  any 
crime  committed.  At  last  the  new  criminal  code  as  proposed 
by  Mr  Justice  Stephen  would  make  the  man's  power  of  con- 
trolling his  actions  the  test,  and  with  that  view  every  medical 
man  will  agree.  He  says — "  The  proposition  which  I  have  to 
maintain  and  explain  is,  that  if  it  is  not,  it  oiight  to  be,  the 
law  of  England  that  no  act  is  a  crime  if  the  person  who  does 
it  is,  at  the  time  when  it  is  done,  prevented,  either  by  defective 
mental  power  or  by  any  disease  affecting  his  mind,  from  con- 
trolling his  own  conduct,  unless  the  absence  of  the  power  to 
control  has  been  produced  by  his  own  default."  "WTiile  Judges 
during  three  centuries  were  laying  down  these  rules  of  law, 
men  that  we  now  hold  to  be  insane  were  taking  away  their 


RELATION   TO   MENTAL   DISEASES.  681 

own  lives  by  the  hundred  every  year,  most  of  them  knowing 
it  to  be  wrong  and  yet  doing  it — a  "crime,"  and  a  "motive- 
less" one  in  most  cases.  Those  suicides  were  surely  thus 
exhibiting  to  all  who  had  eyes  to  see,  that,  in  such  cases  at 
all  events,  something  was  interfering  to  make  inoperative 
every  natural  instinct,  every  effort  of  will,  and  every  motive 
of  ordinary  human  action — that  something  being  disease  and 
disordered  function  of  the  brain. 

No  doubt  there  are  many  difficult  cases — cases  on  the 
borderland  of  disease,  cases  where  vice  and  mental  disease 
are  mixed  up  puzzlingly,  cases  of  mild  enfeeblement  of  mind, 
cases  of  drink  voluntarily  taken,  when  its  effects  were  well 
known,  and  after  being  taken  crime  has  been  committed  in 
a  condition  of  delirium  or  short  frenzy.  "We  must  admit  we 
have  no  definite  test  as  yet  for  detecting  minute  degrees  of 
mental  disturbance.  I  only  wish  we  medical  men  were  placed 
in  a  more  satisfactory  position  before  giving  evidence.  The 
whole  facts  on  both  sides  are  seldom  put  before  us,  and  we 
are  often  regarded  and  treated  in  the  witness-box  as  partisans 
— a  position  that  we  should  resent  as  derogatory  to  science. 
Either  we  ought  to  be  appointed  as  Assessors  to  the  Court, 
or  the  Court  should  ask  for  our  Report  on  which  we  could 
be  cross-examined.  At  present  many  of  the  persons  solemnly 
condemned  to  death  for  the  crime  of  murder  are  found  after- 
wards to  be  insane  by  a  private  medical  inquiry  ordered  by 
the  Home  Secretary,  no  evidence  as  to  the  prisoner's  mental 
state  having  been  submitted  to  the  judge  and  jury. 

6.  We  are  often  appealed  to  as  to  the  capacity  of  a  man  to 
maJce  a  loill,  or  to  transact  ordinary  business,  to  enter  into 
ordinary  contracts,  or  to  contract  marriage.  In  the  Scotch 
Courts  an  extraordinary  ruling  has  recently  been  come  to  by 
the  Judges  of  the  First  Division  of  the  Court  of  Session.  A 
petition  for  a  Curator  Bonis  was  presented  to  the  Court  by 
some  of  her  relatives  in  the  case  of  a  young  lady.  The  Judge 
asked  a  report  from  an  expert  as  to  her  mental  capacity. 
She  was  stated  to  be  weak-minded.     The  expert  (Sir  Arthur 


682  DUTIES   OF  MEDICAL   MEN   IN 

Mitchell,  M.D.)  reported  that  she  had  no  legal  capacity  to 
manage  her  affairs.  Before  the  curator  was  appointed  she  had 
been  married,  and  the  Judges  of  the  First  Division  did  not 
go  on  to  appoint  the  curator.  The  contract  of  marriage  was 
thus  virtually  homologated  by  the  Court  in  the  case  of  a  person 
whom  its  own  selected  expert  had  reported  not  to  be  able  to 
manage  her  own  affairs  !  The  principles  on  which  our  opinion 
should  be  founded  for  the  two  latter  purposes  are  just  those 
on  which  we  act  in  determining  the  question  of  sending  a 
patient  to  an  asylum.  In  regard  to  will-making,  great  atten- 
tion has  been  directed  to  the  subject,  and  there  are  certain 
fixed  legal  and  medical  principles  that  should  be  kept  in  mind 
by  us.  The  great  trouble  is  that  we  are  usually  not  consulted 
at  the  time  of  making  the  will,  when  the  real  capacity  of  the 
testator  could  be  examined  into,  but  are  placed  in  the  witness- 
box  after  he  is  dead,  with  one-sided  imperfect  information, 
and  with  every  motive  operating  on  the  side  that  consults  us  to 
prevent  us  getting  at  all  the  facts.  In  will-making  we  must 
enlarge  our  ideas  of  the  disturbances  of  the  mental  functions 
of  the  brain  beyond  those  comprised  under  technical  insanity. 
The  senile  dotard,  the  apoplectic,  the  man  exhausted  in 
strength  from  disease  and  approaching  death,  the  man  con- 
fused in  mind  from  fever  and  drink,  the  man  distracted  by 
terrible  pain,  the  man  whose  condition  is  weakened  so  that  he 
is  made  mentally  unresisting  and  facile  by  disease  and  by  the 
near  approach  of  death,  may  all  require  their  testamentary 
capacity  to  be  tested.  It  is  most  important  that  a  skilled  and 
experienced  medical  man  should  be  asked  to  examine  into  the 
testamentary  capacity  of  such  cases  before  the  destination  of 
great  sums  of  money  is  irrevocably  decided  by  a  document 
that  above  all  things  needs  soundness  of  judgment  for  its 
validity.  It  would  be  well  were  our  profession  more  called 
on  for  this  purpose.  I  was  once  told  by  a  distinguished 
counsel,  with  a  large  experience  in  the  Probate  Court,  that  he 
had  never  known  a  will  upset  where  a  respectable  doctor  had 
witnessed  it  after  examining  into  the  testator's  state  of  mind, 


RELATION    TO   MENTAL   DISEASES.  683 

and  an  agent  of  repute  had  drawn  it  up,  neither  of  them 
taking  any  benefit  under  its  provisions. 

It  may  be  held  as  proved  by  legal  decisions  that  a  lesser 
amount  of  mental  capacity  is  needed  for  making  a  valid  will 
than  for  managing  property  or  enjoying  personal  liberty. 
Patients  in  asylums  have  made  good  wills  during  remissions 
of  their  disease,  the  "  lucid  intervals  "  of  the  older  writers. 
Patients  with  insane  delusions  that  did  not  affect  the  pro- 
visions of  the  will  have  been  held  by  the  highest  tribunals 
to  have  made  good  wills  (Banks  v,  Goodfellow),  Yery  facile 
persons  have  made  good  wills,  and  those  on  the  point  of  death 
constantly  make  wills  that  stand,  while  wills  with  the  most 
absurd  provisions  have  stood  in  law.  There  are  now  three 
cases  in  which  wills  have  been  made  by  patients  immediately 
before  they  committed  suicide,  and  they  have  been  upheld  by 
the  Scotch  Court  of  Session. 

Wlien  a  medical  man  is  asked  to  examine  into  the  testa- 
mentary capacity  of  a  patient  he  should  insist  on  seeing  the 
patient  alone,  or  at  all  events  only  in  .the  presence  of  a  nurse 
or  a  family  agent,  and  the  first  thing  to  be  ascertained  is  this 
— (a)  "Is  the  patient  free  from  the  influence  of  drink  or 
drugs,  and  in  his  usual  state?"  Then — (&)  "Does  he  know 
the  nature  of  the  act  he  is  to  perform,  and  the  efi"ect  of  the 
document  he  is  to  sign?  "  The  next  thing  (c)  is  to  find  out 
if  he  is  not  influenced  in  the  doing  of  it,  or  in  regard  to  any 
of  its  provisions,  by  insane  delusion,  or  by  an  insane  or 
morbidly  enfeebled  state  of  mind.  Then  {d)  ascertain  if 
there  is  facihty  of  mind  from  bodily  disease,  intemperate 
habits,  weakness  or  any  other  cause,  or  undue  influence  being 
exercised  from  without.  Here  is  where  you  will  find  the 
benefit  of  being  alone  with  the  patient.  I  remember  an  old 
dying  man  confessing  to  me,  when  alone  with  him  in  these 
circumstances,  that  his  niece,  who  was  also  his  nurse  and 
constant  companion,  was  really  compelling  him  against  his 
judgment  to  make  a  will  in  her  favour,  his  own  volitional 
and  resistive  power  being  weakened  by  his  state  of  bodily 


684  DUTIES   OF   MEDICAL   MEN  IN 

weakness  and  dependence.  The  influence  exerted  on  many- 
patients  in  bodily  weakness,  especially  if  it  has  been  prolonged, 
by  a  nurse  constantly  in  attendance  is  sometimes  absolutely 
dominant,  and  quite  irresistible  by  the  will  of  the  patient. 
A  very  interesting  bit  of  medico-psychology  this  is.  The 
influence  of  previous  intemperate  habits  is  often  so  damaging 
to  the  mental  power  as  to  interfere  with  proper  testamentary 
capacity.     The  memory  is  then  chiefly  afi"ected. 

Supposing  you  are  satisfied  so  far ;  the  next  thing  (e)  is 
to  make  the  intending  testator  go  over  the  particulars  of 
•the  disposition  he  wishes  to  be  made,  without  i^rompting,  or 
suggestion,  or  leading  questions.  And  he  should  be  made 
to  do  this  twice  with  certainly  a  quarter  of  an  hour's  interval 
between  the  two  statements.  It  is  often  well  to  make  him 
tell  the  names  of  all  his  near  relations.  Sometimes  a  man 
wants  to  make  a  will,  whose  memory  is  so  afi'ected  that  he  has 
forgotten  the  existence  and  the  names  of  relations  so  near 
that  they  have  claims  on  his  attention  at  such  a  time.  You 
can  then  see  if  the  disposition  is  a  natural  one,  and  find  out 
from  him  the  motives  for  the  will  being  made,  and  for  any 
provision  of  it  that  may  seem  strange.  Lawyers  and  the 
public  are  apt  to  regard  the  naturalness  and  reason- 
ableness of  the  will  as  being  an  absolute  test  of  whether 
it  should  stand.  In  fact,  are  the  whole  motives  of  action 
of  the  man  quoad  the 'will,  sane,  reasonable,  and  unin- 
fluenced by  morbid  motives  1  Is  it  a  natural  will  in  the 
circumstances?  Is  it  the  act  of  the  man  himself  exercising 
his  own  will  spontaneously  1  I  remember  being  called  to  see 
a  man  who  was  dying  of  bronchitis  and  heart  disease,  with  his 
breathing  impeded,  his  strength  ebbing  away,  and  his  mental 
power  impaired  by  the  non-oxygenated  blood  supplied 
to  his  brain.  He  had  made  a  will  in  favour  of  a  former 
mistress,  and  was  in  a  state  of  great  remorse,  and  wanted  to 
leave  his  money,  which  was  considerable,  to  his  relatives.  But 
he  could  not  twice  over  remember  all  the  provisions — these 
being  a  little  complicated.     I  refused  on  this  account  on  two 


EELATION  TO   MENTAL   DISEASES.  685 

occasions  to  say  he  had  testamentary  capacity.  But,  as  some- 
times happens,  he  became  more  clear  in  mind  before  death, 
and  I  Vas  hurriedly  sent  for  late  one  night  to  see  him.  He 
went  clearly  twice  over  the  provisions  he  wished  made  in  his 
will,  and  told  me  why  he  wished  these  made.  His  reasons 
were  natural  and  right.  The  lawyer  was  there  with  the  docu- 
ment drawn  up,  and  the  testator  had  just  power  to  make  his 
mark  before  he  died.  Yet  this  will  was  held  good  in  law  in 
spite  of  an  attempt  to  upset  it.  (/)  Ascertain  if  possible  from 
him  if  he  had  intended  to  will  his  property  as  proposed  before 
his  illness,  and  for  how  long.  Try  and  get  independent  testi- 
mony from  others  on  this  point.  The  next  thing  (g)  you  have 
to  ascertain  is  if  the  intending  testator  knows  in  a  general 
way  the  amount  of  the  property  he  has  to  bequeath.  I  lately, 
on  getting  to  that  point  in  the  case  of  a  very  sensible-looking 
man,  was  astonished  at  being  told  by  him  that  he  was  worth 
£100,000,  which  I  knew  to  be  quite  impossible,  and  of  course 
no  will  was  made,  (h)  Ascertain  what  brain  disease,  if  any, 
the  patient  labours  under,  carefully  considering  the  question 
as  to  whether  the  convolutions  are  affected  by  such  disease. 
The  most  common  brain  disease  under  which  patients  will  be 
found  to  labour  is  apoplexy  or  paralysis.  This  may  exist  in 
any  degree,  and  may  be  accompanied  by  any  mental  condition 
from  almost  perfect  soundness  and  force  up  to  complete  fatuity, 
facility,  and  want  of  memory.  The  usual  morbid  emotional 
outbursts  of  weeping,  or  irritability,  especially  if  the  patient 
is  aged,  often  indicate  loss  of  mental  power  and  of  volitional 
resistance. 

It  is  most  necessary  not  to  let  a  good  motive  make  us 
sanction  a  bad  will,  however  natural  its  provisions  may  be, 
however  much  trouble  or  expense  it  may  save.  I  am  fre- 
quently asked  to  sanction  wills  being  made  by  persons  unfit 
to  make  them,  on  account  of  the  convenience  of  having  a  will 
or  the  saving  of  expense  and  trouble.  I  have  found  but  little 
realisation  of  the  impropriety  or  illegality  of  getting  dying 
people,  or  those  whose  minds  were  enfeebled  from  paralysis. 


686  DUTIES   OF   MEDICAL   MEN   IN 

who  did  not  really  know  what  they  were  doing,  to  sign  wills  as 
a  matter  of  convenience,  even  among  conscientious  reputable 
people.  In  examining  patients  as  to  will-making  it  is  very 
necessary  and  desirable  to  be  perfectly  impartial,  to  make  no 
suggestion  and  express  no  opinion  of  one's  own  as  to  the  justice 
or  propriety  of  the  settlement  to  be  made,  and  on  no  account 
to  say  anything  that  would  influence  the  testator  in  his  views 
as  to  the  disposition  of  his  property. 

7.  The  detection  of  feigned  insanity  is  a  duty  sometimes  laid 
on  a  medical  man.  There  are  no  fixed  rules  or  tests  by  which 
feigned  insanity  can  be  detected.  I  need  hardly  say  we  have 
first  to  see  if  the  type  presented  is  that  of  an  ordinary  kind  of 
insanity.  Most  imitators  mix  up  incoherent  maniacal  symp- 
toms with  silliness,  and  will  talk  no  sense  at  all,  and  pretend  to 
know  nothing.  In  fact  they  overdo  their  part.  The  patient 
should  be  carefuUy  watched  aU  the  time,  sometimes  ostenta- 
tiously watched  to  keep  him  at  it  for  a  long  time,  and  then 
again  when  he  does  not  know  he  is  observed.  ^N'o  sane  man 
can  imitate  the  dry  skin  and  Hps,  furred  tongue,  constant 
restlessness  by  day  and  night,  high  temperature,  and  constant 
sleeplessness  of  acute  delirious  mania  which  for  a  short  time 
feigners  often  try  to  simulate.  A  man  imitating  the  shouting, 
&c.,  of  acute  mania  perspires  freely,  while  an  acutely  maniacal 
patient  seldom  does  so.  The  sensibility  to  pain  should  be 
tested,  and  sometimes,  in  prisons,  a  battery  is  found  useful 
in  the  case  of  old  crafty  malingerers.  I  have  heard  of  a  man 
being  put  under  the  influence  of  a  drug  before  the  doctor  was 
known  to  be  coming,  in  order  to  produce  a  real  stupidity  with 
confusion  of  mind.  I  have  been  deceived  by  a  clever  imitator 
of  acute  mania  so  far  as  my  conclusions  were  arrived  at  from 
one  visit.  Epilepsy  and  epileptic  mania  are  very  commonly 
imitated. 

I  have  known  a  really  insane  man  assume  an  exaggerated 
insanity  to  make  his  friends  think  the  asylum  was  doing 
him  harm;  and  a  sort  of  grotesque  semi-voKtional  imitation 
of  mania  is  common  in  hypochondriacal  melancholies  to  con- 


RELATION   TO   MENTAL  DISEASES.  687 

vince  tlieir  friends  how  ill  they  are ;  while  in  hysterical  girls 
imitations  of  maniacal  attacks  and  of  unconsciousness  are  very 
common  "to  excite  sympathy  and  attract  attention. 

8.  One  of  the  most  difficult  o,nd  often  most  responsible  duties 
that  fall  to  a  medical  tnarHs  lot  is  to  give  confidential  family 
advice  about  engagements  to  marry  when  one  party  has  been 
insane,  is  threatened  ivith  insanity,  or  has  an  insane  heredity, 
to  advise  as  to  the  education  and  profession  of  children  of  a 
very  neurotic  heredity,  or  to  advise  as  to  the  significance  of 
sudden  changes  of  conduct  and  sudden  oidhreaks  of  gross  im- 
morality, or  of  a  tendency  to  unnatural  crime,  or  other  motive- 
less and  unaccountable  conduct  in  previously  reputable  sane 
people.  Such  advice  may  have  the  most  serious  consequences. 
My  feeling  is  always  against  the  marriage  of  women  who 
have  been  insane.  I  always  advise  young  men  or  young 
women  to  avoid  marrying  into  a  very  neurotic  and  insane 
stock.  The  risk  is  very  great.  I  quite  agree  with  the 
French  medical  opinion  that  there  is  a  special  tendency  for 
members  of  neurotic  famiHes  to  intermarry,  and  an  affective 
"  affinity  "  among  such  that  tends  towards  love  and  marriage. 
That  is  no  doubt  bad  for  the  race,  and  as  physiologists  we 
should  try  and  stop  it  when  we  can.  To  have  a  neurotic 
young  man  marry  a  fat,  phlegmatic  young  woman  may  be 
admissible,  and  a  good  safe  stock  may  result.  But  what  are 
we  to  say  about  the  marriage  of  the  neurotic,  thin,  hysterical 
young  women,  with  insanity  in  their  ancestry  1  "We  know 
they  will  not  make  good  or  safe  mothers.  Therefore,  in  them 
we  ought  to  discourage  marriage.  However  good  its  physio- 
logical effect  might  be  on  the  individual,  bad  mental  and 
bodily  qualities,  as  well  as  tendencies  to  disease,  are  pro- 
pagated to  future  generations.  They  leave  the  world  worse 
than  they  found  it  thereby,  the  disease  and  therefore  the 
misery  in  it  being  increased.  The  possible  compensation  of 
a  genius  once  in  an  age  is  not  to  be  trusted  to.  I  believe  a 
healthier  kind  of  genius  would  result  from  better  stock. 
Science,  till  it  discovers  a  way  of  correcting  such  bad  stock, 


688  DUTIES   OF   MEDICAL   MEN   IN 

must  say,  "  Do  not  propagate  it."  A  sporadic  case  of  insanity, 
or  of  senile  break-down  imitating  insanity,  may  occur  in 
almost  any  family.  That  would  not  warrant  any  such  advice 
about  the  marriage  of  relations  as  I  have  been  giving.  The 
relatives  of  such  a  case  may  all  be  perfectly  sound.  I  am 
speaking  of  families  in  which  the  neurotic  temperament,  and 
especially  those  in  which  the  nervous  diathesis,  is  present. 
If  such  persons  are  to  marry,  do  not  let  them  marry  too 
young,  and  let  them  marry  into  a  sound,  muscular,  fat,  non- 
nervous  stock.  Though  the  contrary  has  been  the  rule,  my 
advice  has  over  and  again  been  taken,  and  engagements  to 
marry  not  entered  into  on  the  ground  of  bad  heredity.  If 
you  are  asked  about  any  young  man  or  woman — "  Will  he 
or  she  become  insane  or  not  1  "^say  that  science  does  not 
yet  enable  us  to  answer  that  question  certainly. 

As  to  the  mode  of  education  of  the  children  of  insane  or 
neurotic  parents,  there  can  be  no  doubt  whatever  that  it 
ought  to  be  on  very  stringent  physiological  lines,  and  under 
medical  advice.  Such  children  should  all  be  brought  up  in 
the  country,  and  fed  mostly  on  milk  and  cereals,  and  should 
have  lots  of  fresh  air,  and  no  improper  excitement ;  they 
should  have  well-ventilated  class-rooms,  short  school-hours, 
and  their  lives  and  time  should  be  systematised.  Their  weak 
points  should  be  corrected  by  their  modes  and  conditions  of 
Kfe.  They  should  be  kept  fat,  if  possible,  one  and  all.  They 
should  have  no  alcohol,  and  no  tobacco  till  after  twenty-five. 
At  the  coming  on  of  the  reproductive  period  of  life  special 
care  should  be  taken  with  them.  The  sexual  appetite  is  most 
difficult  to  manage  in  them  and  by  them.  It  is  often  strong, 
disturbed,  and  apt  to  take  unnatural  forms,  while  the  power 
of  control  over  it  is  apt  to  be  smaU.  Erotic  imaginations  are 
apt  to  become  the  dominant  factors  of  life  and  conduct.  The 
occupations  they  choose  should  not  imply  intense  head  work, 
nor  a  sedentary  life,  nor  excitement.  Make  them  colonists, 
sending  them  back  to  nature,  or  get  them  into  fixed  salaried 
places  with  systematic  work   and   a   regular   holiday.     The 


RELATION   TO   MENTAL   DISEASES.  689 

worst  of  it  is  that  such  persons  often  tend  to  do  exactly  the 
reverse  of  all  this.  Some  especially  neurotic  children  need 
very  special  modes  of  education.  I  have  seen  cases  who  could 
not  safely  be  sent  to  ordinary  schools.  Through  precocious  steal- 
ing, lying,  and  vice  they  were  constantly  getting  into  trouble. 
They  were  without  much  moral  sense  or  self-control,  and  had 
erratic,  motiveless  ways.  I  have  seen  good  results  with  such 
children  sometimes  by  placing  them  in  a  quiet  family  in  the 
country,  under  motherly  care,  under  special  rules  and  guid- 
ance, and  away  from  much  temptation.  Such  children  are 
the  stock  out  of  Avhich  the  insane,  the  masturbators,  the 
dipsomaniacs,  and  the  motiveless  "instinctive"  criminals  arise, 
with  a  poet  or  a  genius  to  redeem  the  class  once  in  a  century 
and  to  vindicate  nature's  law  of  compensation  in  the  world. 


2  X 


LECTUEE    XX. 

A  SUMMAEY  OF  THE  GEISTERAL  TREATMENT 
AND  MANAGEMENT  OF  INSANITY  LOOKED 
AT  AS  A  WHOLE:  AND  ON  THE  USE  OF 
HYPNOTICS,  SEDATIVES,  AND  MOTOR  DE- 
PRESSANTS. 

Insanity  as  a  disease — Urgent  questions  to  be  faced  as  to  causation, 
heredity,  diathesis,  former  diseases,  concealment  of  symptoms — 
Mental  symptoms — Bodily  symptoms — Examination  of  patient — 
Diseases  that  simulate  insanity — Dangers — Treatment — Nursing — 
Home  treatment — Treatment  in  lodgings  or  hired  house — Asylum 
treatment — Why  a  patient  should  be  sent  to  an  asylum — Legal 
forms— Food  and  feeding — Food-medicines — Alcoholic  stimulants — 
Tonics  and  nerve  stimulants — Exercise  and  fresh  air  versus  rest — 
Occupation  and  amusements — Hypnotics,  sedatives,  and  motor  de- 
pressants— General  principles  of  use — Dangers  of  abuse — What  do 
we  desire  to  attain  ? — Opium  in  melancholia — Paraldehyde — Sul- 
phonal — The  bromides  and  cannabis  indica — Hyoscine. 

The  different  varieties  of  insanity  have  for  tlie  most  part 
different  symptoms,  risks,  and  terminations,  and  tliey 
commonly  imply  some  difference  of  treatment,  but  they  have 
also  many  features  in  common  in  management  and  treatment. 
A  man's  "mind  is  affected,"  and  with  this  there  are  bodily 
symptoms.  The  practitioner  has  therefore  before  him  a 
"  disease,"  as  popularly  understood,  to  treat.  From  this 
point  of  view  it  may  be  useful,  especially  to  busy  practi- 
tioners, in  this  closing  lecture  to  summarise  and  condense  the 
views  scattered  over  the  preceding  lectiires,  and  to  enunciate 
the  general  principles  of  treatment  applicable  to  insanity  as  a 
whole.     I  have  often  been  asked  to  do  so  by  medical  friends, 


SUMMAKY  OF  TREATMENT  OF  INSANITY.  691 

who  found  the  discussion  of  the  special  varieties  of  the  disease 
and  the  clinical  illustrations  too  long  for  emergencies. 

Urgent  Questions. — When  a  patient's  mind  has  given  way, 
or  is  threatening  to  do  so,  there  are  certain  questions  that  the 
doctor  should  pass  before  his  mind  seriatim,  and  come  to  some 
sort  of  conclusion  about  them,  either  at  the  time  or  as  the  case 
develops.  The  chief  of  these  are: — What  is  the  probable 
cause  of  the  mental  disturbance  ?  Is  it  from  within  the  man 
or  from  without  him  ?  An  evolution  of  his  heredity  ?  An 
almost  necessary  incident  in  his  development  or  decadence  ? 
A  result  of  the  conditions  of  his  previous  life,  his  environment 
having  been  inharmonious  ?  Had  he  by  his  conduct  or  mode 
of  Hf e  anything  to  do  with  bringing  on  the  disease  1  or  is  it 
the  direct  result  of  some  cause  from  within  ?  Then  comes  the 
further  question — Are  there  more  causes  than  one  in  opera- 
tion 1  Most  cases  have  more  than  one  cause.  It  will  depend 
on  how  these  questions  are  answered  whether  the  next  can 
be  favourably  regarded.  Can  the  cause  or  causes  be  removed, 
and  how  1  The  relatives  will  always  have  a  cause  for  sucli 
a  strange  thing  as  insanity. 

It  is  most  important  in  most  cases  to  get  information  as  to 
the  heredity  of  the  patient,  both  in  regard  to  mental  disease 
and  the  neuroses ;  and  it  is  well  to  find  out  the  heredity 
and  personal  diathesis  especially  in  regard  to  consumption, 
rheumatism,  gout,  syphilis,  &c.  The  developmental  diseases 
which  the  patient  has  suffered  from  should  not  be  lost  sight 
of,  especially  the  early  neuroses.  The  next  set  of  questions 
relate  to  the  symptoms  present :  Are  all  the  symptoms  really 
exhibited  ?  or  is  the  patient,  by  voluntary  eiTort  or  otherwise, 
concealing  important  symptoms?  Is  there  much  below  the 
surface  of  the  case  ?  Remember  that  relatives  and  friends 
tend  to  minimise  certain  mental  symptoms  and  greatly  to 
exaggerate  others.  They  think  little  of  mental  depression 
and  delusions  so  long  as  the  outward  conduct  is  not  much 
changed,  while  they  are  frightened  unduly  about  incoherence, 
threats,  noise,  or  violence,  or  about  what  seems  to  them  loss 


692  SUMMARY  OF  TREATMENT  OF  INSANITY. 

of  consciousness.  To  what  extent  are  the  symptoms  purely 
mental  or  chiefly  mental,  and  to  what  extent  are  there  bodily 
symptoms  or  accompaniments?  Have  they  come  on  gradually 
or  suddenly  ?  Are  they  progressing  or  stationary  ?  Are  the 
great  organic  functions  aff'ected  or  not  ? 

Mental  Symptoms. — Depression,  elevation,  excitement,  de- 
lusions, stupor,  impulsiveness,  silliness,  loss  or  perversion  of 
affections,  incoherence  of  speech,  loss  of  memory,  mental  auto- 
matism, dominating  and  fixed  ideas,  suicidal  and  dangerous 
tendencies,  are  the  chief  mental  symptoms  to  be  inquired  into. 

Bodily  Symptoms. — These  are  present  in  most  cases  of  in- 
sanity. Preliminary  headaches,  all  kinds  of  perverted  sensa- 
tions in  head  and  in  body,  sleeplessness,  losing  of  flesh,  anorexia, 
constipation,  changed  expression  of  face  and  eye,  changed 
tastes  for  food  and  drink,  altered  secretions,  slightly  elevated 
temperature,  with  a  tendency  to  an  evening  rise,  tremblings  of 
facial  muscles,  impaired  articulation,  especially  in  the  case  of 
difficult  words,  a  dry  skin,  motor  paralysis,  are  the  chief  bodily 
symptoms  in  ordinary  cases  to  be  inquired  into.  The 
question  must  always  be  asked.  Is  there  organic  disease  of 
the  brain,  or  spinal  cord,  or  nerves? 

Examination  of  Patient. — The  examination  into  every  bodily 
symptom,  into  the  condition  of  every  organ,  cannot  be  too 
thorough.  Mental  symptoms  constantly  depend  on  reflex 
irritation  of  the  cortex  from  the  peripheral  organs.  Always 
try  to  find  a  bodily  cause  for  a  delusion. 

Diseases  that  Simulate  Insanity. — Keep  in  mind  that  though 
the  dehrium  of  fevers  is  emphatically  mental  disorder,  it  is 
not  reckoned  technical  insanity  that  should  be  certified  and 
sent  to  asylums.  The  following  are  the  chief  diseases  that 
may  be  attended  by  cerebro-mental  symptoms  simulating 
insanity,  viz.,  typhoid,  typhus,  small-pox,  scarlet  fever  before 
the  eruption  comes  out,  meningitis,  traumatic  injury  to  head, 
mental  shock,  hysteria,  urtemic  dehrium  and  coma,  cerebro- 
spinal meningitis,  drunkenness,  the  effects  of  opium  and  other 
neurotic  drugs. 


SUMMARY   OF   TEEATMENT   OF   INSANITY.  693 

Danger. — Then  comes  the  very  urgent  question  of  danger. 
Does  it  exist  ?  and  in  what  form  1  What  are  the  risks,  in 
short  ?  'j^re  they  to  the  patient's  life,  by  direct  attempts  at 
suicide  ?  or  by  indirect  means,  such  as  taking  too  Httle  or  no 
food  ?  Are  there  risks  to  others  1  and  to  whom  ?  Is  there 
risk  of  exhaustion  by  excessive  cortical  action?  Or  are  the 
risks  those  of  neglect  of  organic  functions?  Or  neglect  of 
the  conditions  of  life  necessary  for  health  or  recovery,  such 
as  exercise,  fresh  air,  rest  or  sleep?  Eisks  to  reputation,  to 
fortune,  to  business,  to  position,  have  all  to  be  thought  of.  A 
medical  man  cannot  be  too  candid  with  the  relatives  and 
friends  of  a  mentally  affected  patient  as  to  the  risks  of  the 
case. 

Treatment. — ^Then  comes  the  most  serious  question  of 
Treatment  and  Management.  Almost  the  first  tiling  to  be 
considered  in  all  such  cases  is :  who  is  to  be  the  responsible 
nurse,  or  companion,  or  observer  of  the  case  ?  Can  a  really 
good,  experienced,  skilful  nurse  or  attendant  be  got?  This 
is  a  sine  qua  non  in  most  cases.  A  "bodily  nurse,"  even  a 
good  one,  is  often  quite  unreliable,  both  for  the  observation 
of  mental  symptoms,  for  appreciating  risks,  for  acting  in 
emergencies,  and  even  for  the  routine  treatment  and  manage- 
ment. Good  nurses  can  often  be  got  from  asylums,  and  most 
nursing  institutions  have  nurses  with  "mental"  experience 
and  training.  The  Medico-Psychological  Association  has 
lately  instituted  a  course  of  training  and  an  examination  that 
will  no  doubt  in  time  produce  a  body  of  trained  male  and 
female  attendants  and  mental  nurses  available  for  the  public, 
each  with  a  certificate  that  will  be  a  guarantee  of  fitness  and 
character.  In  some  cases  the  disease  can  be  cut  short  by 
treatment  or  by  altering  the  conditions  of  life.  Change  of 
scenery  often  is  good.  Travel  is  good  in  the  very  beginning 
of  a  few  mental  cases,  but  it  should  not  be  fast  travel.  A  sea 
voyage,  that  favourite  recommendation  of  despair,  often  does 
far  more  harm  than  good,  and  is  attended  with  many  risks. 
How  many  suicides  have  I  known  to  result  from  this  cause  ! 


694  SUMMARY   OF   TEEATMENT   OF  INSANITY". 

A  course  of  mineral  waters  and  baths,  or  a  hydropathic  with 
a  good  system  of  baths,  is  a  far  safer  recommendation,  and 
suitable  for  more  cases,  but  even  that  is  often  too  pubhc  or 
too  exciting. 

Home  Treatment,  Treatment  in  Lodgings,  and  Asylum  Treat- 
ment.— It  is  one  of  the  most  important  decisions  that  has 
to  be  come  to  in  the  treatment  of  decided  mental  disease, 
whether  the  patient  shall  remain  at  home,  shall  be  sent  to 
suitable  lodgings,  or  shall  be  sent  to  an  asylum.  There  are 
comparatively  few  grave  cases  except  acute  puerperal  mania, 
short  attacks  of  delirious  mania  and  alcohohsm,  that  can  be 
best  treated  at  home,  and  then  only  among  the  well-to-do, 
where  good  nursing  and  suitable  rooms  can  be  got,  and  the 
attack  does  not  last  long,  runs  a  definite  course,  and  does  not 
need  for  its  treatment  much  open  air  and  exercise.  Wlien 
a  case  of  mental  disease  becomes  quiet  and  chronic,  with  no 
urgent  symptoms  and  no  great  tendency  to  degeneration  of 
habits  or  mental  condition,  home  is  sometimes  a  suitable 
residence  if  there  is  a  responsible  head  of  the  house,  personal 
nursing,  and  general  medical  guidance. 

When  the  case  is  not  doing  well  at  home  or  is  not  likely  to 
do  well,  then  comes  the  question  of  a  hired  house  or  rooms, 
to  be  tried  before  an  asylum  is  resorted  to,  or  during  the 
whole  attack.  In  selecting  a  house  or  rooms  the  following 
principles  should  guide  us.  It  should  be  in  the  country  or  in 
the  quiet  suburbs  of  a  town,  but  not  too  isolated.  It  should 
have  an  inclosed  garden  with  good  walks.  It  should  have 
easy  access  to  the  country  roads.  Eooms  on  the  ground  floor 
should  nearly  always  be  selected.  Before  use,  aU  door  keys 
should  be  taken  out  and  kept  by  the  nurse.  If  an  inside  bolt 
is  on  the  W.C.  it  should  be  taken  off,  and  the  windows  should 
have  stops  put  on,  so  that  the  loAver  sash  cannot  be  raised 
more  than  five  inches.  Sunshine  and  cheerfulness  should  be 
prime  motives  for  selecting  a  living-room. 

During  the  treatment  in  rooms  medical  visitation  should  be 
frequent ;  this  has  a  good  moral  effect  on  the  patient,  and 


SUMMARY   OF  TREATMEISIT   OF  INSANITY.  695 

keeps  the  nurses  up  to  the  mark  and  prevents  them  thinking 
they  are  only  "  keepers  "  for  the  safety  of  the  patient  rather 
than  nui'ses  for  his  cure.  All  precautions  against  suicide  and 
danger  should  be  carefully  taken  and  stringently  enforced. 
If  the  case  lasts  long,  special  means  must  be  taken  to' provide 
amusement  for  the  patient  and  break  the  monotony.  Visits 
of  relatives,  while  often  exciting  and  harmful  in  the  acute 
stage,  do  much  good,  and  keep  everybody  up  to  the  mark  later 
on.  Change  of  rooms  may  be  needful  to  secure  change  of  air 
and  scene. 

I  have  treated  almost  every  kind  of  case,  from  acute, 
violent,  raving  mania  to  the  mildest  melanchoha,  in  private 
houses  and  in  lodgings,  and  very  many  with  success.  It  is 
largely  a  question  of  house,  nurse,  and  money.  It  is  of  course 
very  expensive,  seldom  coming  to  less  than  at  the  rate  of 
seven  pounds  a  week  all  told,  and  often  much  more  if  three 
or  four  nurses  are  needed. 

The  forms  of  insanity  most  suitable  for  treating  in  such  a 
way,  or  that  it  is  most  desirable  so  to  treat,  are  mild  melan- 
choha, adolescent  insanity  while  recent,  puerperal  insanity, 
some  cases  of  hysterical  insanity,  mild  cases  of  mania  that 
look  as  if  they  would  run  a  short  or  regular  course,  lacta- 
tional insanity,  that  of  pregnancy,  senile  insanity  in  the  very 
aged,  and  some  cases  of  alcoholic  insanity. 

The  advantages  are  that  the  "name  of  an  asylum"  and  of 
technical  insanity  is  avoided,  a  most  important  matter  in  some 
cases.  Professional  reputation  and  success  are  less  likely  to 
suffer ;  appointments  run  less  risk ; .  the  patient  is  far  better 
pleased  when  he  recovers,  and  his  friends  are  more  satisfied. 
But  the  patient's  recovery  must  be  the  paramount  considera- 
tion. He  has  the  right  to  have  the  best  chance  of  Hving,  and 
not  dying  mentally.  Its  disadvantages  are  the  want  of  con- 
stant medical  supervision  and  of  a  medical  routine  of  life 
and  disciphne,  the  difficulty  of  getting  responsible  and  skilled 
nurses,  the  want  of  freedom  of  walking  in  some  cases,  the 
risk  of  disturbing  neighbours,  the  greater  risk  of  suicide,  the 


696  SUMMARY   OF   TREATMENT   OF   IXSAXITY. 

friction  of  nurse  and  patient  left  so  long  together,  tlie  irrita- 
tion of  personal  control,  the  monotony  of  the  Hfe,  and  the 
want  of  the  stimulus  of  institution  life. 

Poverty  almost  always  implies  an  asylum  as  securing  the 
best  treatment  in  nearly  all  forms  of  insanity.  Long  con- 
tinuance of  acute  symptoms  also  does  so.  Intense  and 
subtly-schemed  suicidal  attempts,  great  violence  and  homi- 
cidal impulses,  very  dirty  habits,  much  noisiness,  and  non- 
recovery  after  a  reasonable  time,  should  suggest  asylum 
treatment.  Remember  that  the  nurses  may  be  a  Httle  influ- 
enced in  their  reports  by  the  fact  that  their  pay  ceases  when 
the  case  is  removed  from  their  care,  and  we  ourselves  are  in 
the  same  position.-  A  good  asylum  has  the  advantage  of  a 
healthy  situation,  large  grounds,  extensive  walks,  a  suitable 
dietary,  a  healthy  regime  of  living,  regularity,  order,  system, 
which  in  many  cases  are  all  most  therapeutic.  It  has  proper 
rooms  for  violent  cases,  plenty  of  skilled  nursing  and  medical 
supervision  that  can  scarcely  be  obtained  at  home  or  in 
lodgings ;  then  it  has  suitable  occupations  and  amusements. 
Good  modern  asylums  have  special  means  of  segregating  the 
different  classes  of  patients.  The  different  parts  of  the  house 
are  specially  adapted  to  the  state  and  Cure  of  the  different 
varieties  of  mental  disease.  They  have  villas,  hospital  wards, 
and  seaside  houses.  All  this  makes  for  recovery  most  power- 
fully. Ko  case  should  be  allowed  to  drift  into  incurability 
without  such  an  institution  being  tried. 

Its  disadvantages  are  the  risk  of  annoyance  from  the 
presence  of  fellow-patients  in  a  still  worse  state  of  mind,  the 
seeing  dirty  and  degraded  cases  that  shock  a  patient  during 
convalescence,  the  risk  that  listlessness  and  apathy  should 
degenerate  into  dementia  from  want  of  interest  in  life,  and 
too  little  exercise  of  vohtional  power.  Some  people,  too,  and 
they  are  of  the  predisposed  neurotic  supersensitive  folks,  have 
all  their  lives  a  foreboding  horror  of  "a  madhouse."  How 
great  a  blessing  it  would  be  to  poor  afflicted  humanity,  both 
the  insane  and  their  much  to  be  pitied  relatives,  if   every 


StJMMAEY  OF   TREATMENT  OF  INSANITY.  697 

vestige  of  prejudice  and  terror  were  removed  from  the  idea 
of  a  mental  hospital ! 

A  doctor  sending  a  case  to  an  asylum  should  have  in  mind 
that  there  are  tvro  events,  either  of  which  will  probably  make 
the  relatives  blame  him  for  having  made  a  mistake  in  recom- 
mending the  step — these  are  death,  or  recovery  within  a  week 
or  a  fortnight  after  admission.  If  the  latter  occur,  the  patient 
will  be  likely  to  join  in  the  disapproval. 

Legal  Forms. — Before  an  asylum  is  decided  on,  the  relatives 
should  be  distinctly  told  that  it  implies  formal  legal  papers 
and  medical  certificates  being  filled  up,  and  that  a  magistrate's 
or  sheriff's  order  will  be  needed — all  this,  though  not  imply- 
ing publicity,  yet  placing  the  patient  in  the  category  of  the 
technical  insane.  The  full  reasons,  pro  and  con,  should  be 
explained  to  them,  and  I  always  advise  my  medical  friends 
not  to  be  too  urgent,  but  to  temporise  for  a  little  if  the 
relatives  are  unwilling  or  will  not  give  immediate  consent, 
except  the  symptoms  are  very  urgent  or  very  dangerous  in 
character.  Let  them  see  the  patient,  and  be  fully  convinced 
of  the  expediency  and  necessity  of  the  step  in  the  patient's 
interests.  The  forms  required  can  be  got  at  any  asylum, 
usually  also  from  any  inspector  of  poor  in  Scotland.  When 
there  are  no  special  reasons  to  the  contrary,  it  is  usually  far 
better  for  the  patient  to  be  taken  to  the  asylum  by  a  near 
relative  and  nurse  or  attendant  than  the  family  doctor. 
Especially  the  asylum  doctor  should  have  nothing  directly  to 
do  with  it  if  he  can.  Don't  let  him  be  connected,  in  the 
patient's  mind,  with  the  decision  to  be  sent  from  home,  and 
avoid  deceiving  the  patient.  Commonly  say  that  he  is  to  be 
placed  under  a  doctor's  care  in  order  to  get  better.  I  know 
the  difficulty  of  this,  and  the  terrible  temptation  to  deceive 
him  as  to  his  destination ;  but  the  effect  of  such  deception  is 
often  very  bad  for  him,  and  lastingly  so.  It  makes  him  sus- 
picious of  every  one,  and  sets  his  back  up  against  necessary 
treatment.  In  my  experience,  human  ingenuity  in  prevarica- 
tion reaches  its  limits  in  the  lies  told  to  jDatients  as  to  where 


698  SUMMAKY  OF   TREATMENT   OF   INSANITY. 

they  are  going,  and  why  they  are  going,  when  they  are  being 
brought  to  asylums.^ 

Food  and  Feeding. — In  all  cases  the  questions  of  food  and 
feeding  is  one  of  the  first  considerations.  Food  must  always  be 
tempting,  nourishing  and  well  served,  For  most  acute  cases  it 
requires  to  be  liquid  or  nearly  so,  and  often  repeated.  Nothing 
is  so  good,  and  nothing  can  be  given  so  easily,  as  milk  or  liquid 
custards,  each  made  of  a  pint  of  milk,  just  under  the  boiling  point, 
into  which  two  or  three  eggs,  after  being  beaten,  are  stirred 
in  with  sugar,  a  tablespoonful  of  sherry,  and  a  Kttle  nutmeg. 
One  of  these  custards  is  a  meal,  which  the  patient  can  drink 
off  in  a  minute ;  or  if  he  refuses  absolutely,  it  can  be  poured 
into  his  stomach  quite  easily  through  a  funnel  attached  to  a 
long  rubber  tube,  !N"o.  12  or  14  catheter  size,  passed  through 
one  nostril.  Strong  soups,  with  plenty  of  vegetable  juice, 
jellies,  and  fruit  juices,  can  also  be  easily  given.  Depend 
upon  it,  under-feeding  is  far  more  risky  to  recovery  than  over- 
feeding. Patten  and  nourish  your  patient  is  a  rule  to  which 
there  are  marvellously  few  exceptions  in  mental  medicine. 

Food-Medicines  and  Stimidants.  —  Cod-liver  oil  and  the 
emulsions  of  which  it  is  the  chief  constituent,  and  the  malt 
extracts,  are  exceedingly  useful  in  melancholia,  senile  insanity, 
and  other  cases  with  innutrition.  In  many  such  cases  and  in 
neurasthenic  cases  wines  and  malt  beverages  are  useful  both 
for  digestion,  nourishment,  and  sleep,  and  they  are  easily 
given.  Try  stiff  doses  of  spirits,  suitably  diluted,  to  procure 
sleep  in  some  cases  of  acute  excitement. 

Tonics  and  Nerve  Stimulants. — I  use  an  enormous  quantity 
of  quinine  in  the  treatment  of  all  my  patients  who  are  run 
down  in  body,  or  whose  appetites  are  poor.  I  also  use  much 
iron  in  ansemic  cases,  and  the  dilute  mineral  acids  are  distinct 
brain  stimulants,  as  experimentally  demonstrated  by  Professor 
Eoy.  The  whole  class  of  tonics  is  of  undoubted  service  and 
should  be  largely  given,  each  medicine  for  five  or  six  weeks, 

1  See  paper  by  Dr  F.  A.  Elkins  in  Edinhurgh  Medical  Journal,  March 
1892. 


SUMMARY  OF  TREATMENT  OF  INSANITY.  699 

and  then  a  change  of  tonic  being  made.  The  class  of  direct 
nerve  stiraulants,  of  which  strychnine  is  the  best  type,  and 
which 'forms  the  most  active  constituent  of  the  numerous 
syrups  (Easton's,  Fellow's,  &c.),  should  not  be  given  indis- 
criminately. They  may  cause  cortical  excitement ;  they 
often  stimulate  the  sexiial  nisus,  and  they  frequently 
aggravate  insomnia.  They  are  not  suitable  in  most  acute 
cases,  nor  in  excitable  motor  melancholies,  most  supersensitive 
neurasthenics,  most  hysterical  and  masturbational  cases,  and 
whenever  convulsive  symptoms  exist.  But  in  early  simple 
melancholia,  in  most  cases  where,  the  acute  symptoms  having 
passed  over,  there  is  lethargy  and  a  tendency  to  fall  into 
dementia,  and  where  the  nerve  tone  is  low  without  much 
nervous  excitability,  they  do  much  good. 

Exercise  and  Fresh  Air  versus  Best. — In  my  experience, 
moderate  and  suitable  exercise  in  the  fresh  air  is  one  of  the 
sheet-anchors  of  treatment,  and  is  worth  all  the  physic  if 
there  was  no  choice  between  the  two.  Of  course  it  must 
not  be  taken  up  to  exhaustion.  It  must  be  prescribed  and 
watched  as  a  powerful  medicine  is  prescribed  and  watched. 
We  all  know  that  it  can  soothe  and  stimulate,  can  cure 
insomnia  and  cause  it,  can  help  digestion  and  stop  it,  and 
that  it  may  tend  to  good  bodily  nourishment  or  to  thinness 
according  as  it  is  physiologically  or  injudiciously  used.  It 
manifestly  tends  towards  glandular  action,  towards  regularity 
of  action  of  the  bowels,  towards  normal  metabolism  of  every 
kind.  Wherever  there  is  motor  restlessness  or  nervous 
fidgetiness,  it  affords  the  best  outlet  for  superfluous  energising. 
I  have  tried  massage  as  a  substitute,  so  as  to  get  its  good 
effects  -  without  exhaustion.  My  opinion  of  massage  in 
mental  diseases  is  that  it  suits  very  few  cases  indeed,  and 
does  positive  harm  to  most  melancholies.  Some  psychiatrists 
have  lately  taken  up  rest  as  if  it  were  the  opponent  and 
opposite  instead  of  being  the  complement  of  exercise  in  the 
fresh  air,  and  as  usual  when  a  matter  looks  controversial, 
have  run  down  exercise  and  accused  it  of  doing  serious  harm, 


700  SUMMARY    OF   TREATMENT   OF   INSANITY. 

or  said  it  was  in  many  or  most  cases  not  needed ;  they  quote 
the  starved  and  exhausted  early  melanchohc  when  he  first 
comes  to  an  asylum,  or  the  case  of  "typhoid"  mania,  or  the 
acute  puerperal  woman,  or  the  weak  and  restless  senile  case, 
and  they  say,  "  "We  put  such  cases  to  bed  and  give  them 
rest."  But  who  in  his  senses  ever  exercised  such  cases  more 
than  in  the  gentlest  way,  and  that  only  after  some  days  or 
weeks  of  restful  treatment  ?  Some  physicians  are  now  talk- 
ing of  "  brain  rest  "  by  lying  in  bed  and  being  confined  to  his 
room,  with  gentle  massage,  or  even  by  being  confined  in  a 
strait-jacket,  for  the  acutely  maniacal  patient  who  is  fairly 
strong  and  stout.  By  all  means  let  this  plan  be  tried,  but  my 
whole  medical  experience  has  been  valueless  and  misleading  if 
for  the  majority  of  such  cases  regulated  exercise  in  the  open 
air  is  not  a  remedy,  natural  and  rational,  and  such  "  rest  "  as 
confinement  and  restraint  is  not  an  aggravation.  "  Rest  " 
of  this  sort  for  the  acutely  maniacal  was  tried  in  old  times 
by  restraint  and  seclusion  in  rooms  and  airing-courts,  with 
the  result  of  a  high  mortahty,  a  low  recovery-rate,  and  an 
abundant  residuum  of  chronic  mania  and  dementia,  degraded 
habits,  and  danger  to  themselves  and  others.  I  know  one  or 
two  physicians  who  get  most  of  their  cases  from  large  cities 
adopt  tliis  routine  method  of  putting  every  patient  to  bed  for 
a  few  days,  with  feeding  and  observation.  This  may  suit 
some  cases  well,  but  I  cannot  agree  that  it  is  a  rational  mode 
of  treatment  as  a  routine  measure. 

Occupation  and  Amusement. — The  insane  man  Kke  the  sane 
must  have  something  to  do,  and  we  must  so  condition  his 
work  that  it  takes  up  his  attention,  diverts  him  from  intro- 
spective morbidness,  and  keeps  the  current  of  his  thoughts 
and  feelings  in  physiological  channels.  Simple  mechanical 
work  such  as  gardening  is  best ;  along  with  that  the  natural 
tendencies  towards  social  pleasures  and  amusements  must  be 
strengthened.  For  mental  disease  tends  to  arrest  and  destroy 
the  social  instincts.  To  take  a  man  "  out  of  liimself  "  when 
melancholy,  to  make  him  laugh  when  he  is  sad,  to  provide 


SUMMARY   OF   TREATMENT   OF   INSANITY,  701 

liim  with  cheerful  company  when  lonely,  seem  such  obvious 
measures  of  treatment  that  one  would  have  thought  them 
psychiatric  truisms  as  well  as  being  the  alphabet  of  common 
sense.  Asylums  for  the  insane  have  become  pleasant  hospitals 
and  homes  largely  through  the  slow  development  of  suitable 
occupations  and  amusements  for  the  patients.  The  most 
experienced  and  the  most  thoughtful  of  their  physicians  have 
devised  new  amusements,  and  have  endeavoured  to  apply 
them  as  they  would  medicines  to  each  individual  case.  They 
one  and  all  have  lauded  and  encouraged  such  a  system  of 
moral  and  mental  therapeutics,  and  distraction  from  morbid 
thinking  and  feeling.  But  lately  voices  have  been  raised 
against  this  assured  dogma  of  mental  medicine.  As  usual 
there  is  some  truth  in  the  contention.  There  are  certain  of 
the  insane  for  whose  morbidly  excitable  brains  certain  amuse- 
ments are  unsuitable  or  harmful,  and  in  a  few  of  the  most 
acute  cases  they  are  out  of  the  question.  But  no  physician 
that  I  have  ever  known  ever  used  unsuitable  amusements  for 
such  cases  any  more  than  they  used  strychnine  in  a  convulsive 
case  or  the  bromides  in  stupor. 

Difficulties. — The  general  treatment  of  insanity  needs,  never- 
ceasing  care,  endless  devising  to  meet  individual  symptoms, 
sleepless  vigilance  to  avert  serious  catastrophies,  and  the  most 
watchful  observation  of  symptoms  bodily  and  mental.  It 
implies  a  medical  alertness  and  resource,  a  provision  for 
emergencies  of  all  sorts,  and  a  knowledge  of  human  nature 
that  are  needed  in  no  other  branch  of  therapeutics.  Any- 
thing that  implies  that  "medicine  out  of  a  bottle"  only  will 
cure  the  disease  is  utterly  to  be  deprecated.  The  whole  con- 
ditioning of  a  patient's  life  must  be  faced.  Any  mode  of 
treatment  of  insanity  that  is  easy  is  sure  to  be  wrong. 
Human  nature  is  not  simple,  and  insanity  is  a  disorder  of 
human  nature  in  its  deepest  recesses.  It  has  resulted  from 
departures  from  nature's  laws  for  many  generations.  It 
means  evolutionary  unfitness  for  the  life  struggle.  "We  have 
been  weariedly  struggling  to  understand  what  it  is,  and  slowly 


702  SUMMARY  OF   TREATMENT   OF  INSANITY. 

advancing  in  the  knowledge  that  makes  for  cure.  Let  us  not 
lose  ground  by  retrograde  experiments. 

On  the  Use  of  Hypnotics,  Sedatives,  and  Motor  Depressants 
in  the  Treatment  of  Mental  Diseases} — Four  cases  out  of  five 
of  recent  mental  disease  have  either  sleeplessness,  or  active 
brain  excitement,  or  morbid  motor  activity,  as  part  of  their 
symptoms  at  some  time.  The  other  symptoms  present,  mental 
and  bodily,  often  seem  to  be  of  less  importance  than  those  to 
the  patient's  relatives  and  to  his  physician.  Their  urgency 
and  troublesomeness  seem  to  call  for  direct  and  immediate 
medical  treatment  in  a  very  large  number  of  such  cases. 
While  as  physicians  Ave  fully  recognise  that  these  are  symp- 
toms, and  not  the  disease  itself,  yet  they  all  so  manifestly  tend 
toward  brain  exhaustion,  that  it  is  very  natural  to  adopt  means 
for  their  rehef .  And  the  most  obvious  medical  means  are  the 
use  of  hypnotic,  sedative,  and  motor  depressant  drugs.  I  do 
not  say  that  such  drugs  are  as  curative  as  they  seem,  though 
I  fully  admit  that  their  use  is  sometimes  curative.  And  few 
practitioners  but  frequently  find  their  use  inevitable.  The 
temptation  to  use  them  is  sometimes  overwhelming.  But  the 
dangers  of  using  them  to  excess  are  great  and  numerous.  I 
hope  I  am  not  wrong  in  the  opinion  I  have  formed  that  as 
they  have  been  used  they  have  often  done  more  harm  than 
good  as  regards  cure,  though  it  may  be  said  that  the  sum-total 
of  the  present  relief  they  have  afforded  has  been  so  great  a 
boon  to  the  sufferings  of  humanity,  that  their  disuse  would 
be  a  cruelty  not  to  be  thought  of. 

To  go  into  their  use  fully  in  each  form  and  phase  of  mental 
disease,  in  each  several  temperament,  diathesis,  and  age,  would 
require  a  treatise,  and  our  knowledge  is  not  yet  exact  enough 
to  enable  any  one  to  do  so.  Even  fully  to  state  the  principles 
that  should  guide  us  in  their  use,  so  far  as  I  know  them,  and 
the  risks  to  be  guarded  against,  would  take  up  much  time. 
Now-a-days  most  of  us  want  to  take  our  medical  reading  in  a 

1  Vide  American  Journal  of  the  Medical  Sciences,  April  1889.  A 
paper  by  author. 


SUMMARY   OF   TREATMENT   OF  INSANITY.  703 

concentrated  form.  I  have  had  much  experience  of  their  use 
and  some  proofs  of  their  abuse.  I  have  experimented  care- 
fully with  liiany  sedative  and  hypnotic  drugs,  but  I  find  it 
very  difficult  to  condense  my  experience,  and  lay  down  such 
rules  or  principles  of  general  application  that  would  be  of  use 
to  others. 

When  one  considers  for  a  moment  the  conditions  of  giving 
hypnotics  and  sedatives,  it  is  seen  how  complicated  those  con- 
ditions are.  We  are  giving  drugs  to  act  primarily  and  chiefly 
on  the  functions  of  the  cerebral  cortex,  that  representation  of 
all  organs,  the  co-relator  of  all  functions,  the  differentiator  of 
all  sensations,  the  only  true  originator  of  the  higher  activities, 
mental  and  bodily,  by  far  the  most  dehcate  and  the  most  com- 
plex of  organised  structures  in  nature.  It  is  the  great  inheritor, 
too,  of  hereditary  qualities,  good  and  bad,  and  the  "seat"  of 
mind.  This  governing  organ,  of  such  infinite  delicacy,  has  gone 
wrong  in  some  of  its  highest  functions,  and  we  send  up  to  it, 
through  the  blood,  coarse  chemicals,  or  alter  its  blood  supply, 
or  affect  its  functions  by  reflex  influences  in  order  to  set  them 
right.  In  order  to  have  most  kinds  of  mental  disease  at  all  we 
commonly  need  bad  conditions  of  living  for  many  generations. 
The  cortical  protoplasm  has  become  degenerate  or  disturbed 
through  its  bad  heredity,  and  is  unresistive  to  unphysiological 
conditions  affecting  the  individual,  who  has  probably  for  years 
lived  under  such  evil  conditions.  The  sins  of  ancestry  and  of 
self  at  last  produce  their  natural  fruit  in  an  attack  of  what  we 
call  mental  disease,  but  which  would  be  better  named  cortical 
disease.  We  then  use  powerful  poisons  in  modified  doses  to 
arrest  or  modify  cortical  function.  Who  can  think  that  the 
evil  conditions  of  generations  and  the  unphysiological  courses 
of  half  a  lifetime  will  be  counteracted  by  a  few  doses  of  drugs  ? 
For  we  must  never  forget  in  the  use  of  all  hypnotic  and  sedative 
drugs  whatsoever,  that  essentially  they  are  cortical  poisons 
and  arresters  of  function  when  given  in  fuU  doses.  By  experi- 
menting we  have  found  out  the  doses  that  first  stimulate  and 
then  half  arrest  function.     But  young  medical  men  have  to 


704  SUMMAEY   OF   TKEATMENT   OF  INSANITY, 

learn  for  themselves  by  experience  the  practical  lesson  that 
all  neurotic  medicines  are  in  their  full  action  poisons,  before 
they  realise  the  fact.  We  use  their  half  effects  to  modify 
nervous  energising  in  order  that  modification  in  one  direction 
may  arrest  dangerous  action  in  another,  may  stop  dynamic  ex- 
haustion, and  encourage  tropliic  repair,  may  so  diminish  undue 
reflex  excitability  in  nervous  centres  that  dangerous  reaction, 
mental  and  bodily,  shall  not  take  place.  Such  good  results 
we  try  to  attain  while  we  know  that  in  most  cases  favourable 
conditions  of  life  or  the  vis  medicatrix  really  "  cure "  the 
disease.  The  mere  statement  of  the  problem  shows  its  diffi- 
culties and  its  risks. 

I  would  lay  it  down  as  a  principle  that  few  cases  of  mental 
disease  should  be  treated  by  hypnotics  and  sedatives  alone. 
They  may  be  necessary  in  many  cases  as  a  part  of  the  treat- 
ment, but  there  are  always  other  indications  which  must  be 
carried  out  to  secure  real  and  permanent  recovery.  To  feed 
the  patient,  to  restore  his  nervous  and  nutritive  energy,  to 
rest  his  brain  in  some  cases,  to  restore  to  normal  action  every 
function  that  is  abnormal,  to  direct  his  mental  working  into 
healthy  channels,  to  exercise  his  muscles  and  lower  centres 
so  as  to  get  physiological  and  safe  outlets  for  spare  energy, 
to  improve  his  controlling  powers,  to  restore  his  emotional 
faculties  by  getting  him  to  feel  natural  pleasure  and  interest 
in  something,  to  rouse  his  power  of  attention  to  healthy  and 
safe  objects,  and  by  healthy  and  pleasant  surroundings  to 
make  his  environments  healing — these  must  necessarily  be 
our  first  considerations. 

The  chief  questions  we  should  always  put  to  ourselves,  when 
using  hypnotics  and  sedatives,  are — Are  those  drugs  disorder- 
ing any  other  functions,  while  mitigating  the  wakefulness  and 
restlessness?  Is  the  patient's  mental  state  really  improved 
through  the  sleep  and  quiet  produced?  Is  the  natural  ten- 
dency to  recover  in  any  way  interfered  with?  Does  the 
patient  gain  or  lose  weight  ? — a  most  important  test.  If 
sleeplessness  is   the  most  urgent  symptom,  is  the  continued 


SUMMARY   OF   TREATMENT   OF   INSANITY.  705 

use  of  a  hypnotic  tending  to  restore  the  natural  sleep  habit 
or  not  ?  How  does  the  patient  look  as  to  expression  of  face 
and  eye'a*fter  the  drug  sleep  we  have  been  giving  him  ?  How 
does  he  feel  in  the  morning — refreshed  or  otherwise  ?  Is  the 
use  of  our  drug  forming  a  bad  brain  habit  that  it  will  be 
difficult  to  overcome?  Is  it  causing  a  loss  of  the  higher 
inhibitory  power,  while  giving  the  patient  present  relief? 
There  are  very  many  cases  of  mental  disease  in  the  incipient 
stage,  where  what  is  pleasant  to  him  is  not  necessarily  good 
for  the  patient.  There  are  many  others  where  we  require 
especially  to  strengthen  his  own  volition  to  help  his  cure. 
An  early  case  of  melancholia  that  takes  opium  or  chloral 
may  get  to  like  these  drugs  so  well  that  he  will  not  follow  out 
the  measures  that  will  lead  to  his  real  and  complete  recovery. 

We  need,  before  giving  such  drugs  to  any  case,  first  to  make 
up  our  minds  from  the  symptoms  present  whether  it  is  a  pure 
hypnotic  that  is  needed,  or  a  general  sedative,  or  a  diminisher 
of  reflex  irritability,  or  a  motor  depressant,  or  a  combination 
of  these.  Different  cases  have  such  totally  different  symptoms 
in  mental  disease,  the  sarae  person  is  often  variously  affected 
by  the  same  drug  at  different  times  and  phases  of  his  malady ; 
and  the  drug  tolerance  and  idiosyncrasy  are  so  different  as 
between  one  person  and  another,  that  we  have  much  need 
to  select  our  drugs  carefully  for  the  symptom  and  the  patient 
to  be  treated.  I  would  put  paraldehyde  and  chloral  as  the 
types  of  pure  hypnotics;  sulphonal.as  a  hypnotic  sedative; 
the  bromides  and  their  combinations  with  cannabis  indica  and 
hyoscyamus  as  the  types  of  the  sedatives  and  diminishers  of 
reflex  irritability,  cerebral  and  spinal;  and  hyoscine,  as  the 
type  of  drug  that  especially  depresses  the  functions  of  the 
cortical  motor  centres. 

The  effects  we  may  legitimately  aim  at  and  hope  for  in  the 
treatment  of  mental  diseases  by  hypnotics  and  sedatives  com- 
bined with  other  treatment  are  : — 1.  To  cut  short  a  commen- 
cing attack  of  melancholia  or  mania  in  some  cases.  2.  To 
re-estabhsh   the  sleep-habit   of  the   brain.     3.  To  tide   over 

2  Y 


70G  SUMMARY   OF   TREATMENT   OF   INSANITY. 

sliort  attacks  tliat  liave  a  natural  tendency  to  recover,  tlirougli 
making  the  patient  manageable  by  nurses  in  an  ordinary 
private  house.  4.  To  enable  cases  "with  severe  attacks  to  be 
kept  home  long  enough  to  satisfy  patient's  relatives  that 
the  attack  is  a  "  confirmed  "  one.  5.  To  give  needed  sleep 
and  rest  to  relatives  and  nurses.  6.  To  combat  temporarily 
dangerous  symptoms.  7.  To  take  the  edge  off  the  worst 
symptoms  of  cases  who  are  being  treated  during  a  long  attack, 
so  letting  other  measures  have  full  effect. .  8.  To  subdue 
severe  and  exhaustive  symptoms,  and  so  save  the  patient's 
strength  and  life.  9.  To  satisfy  and  soothe  the  minds  of 
such  patients  as  will  have  some  such  drug.  10.  To  .quiet 
screaming  or  noise  for  the  sake  of  others. 

The  most  common  case  that  has  to  be  treated  by  the 
general  practitioner  of  medicine  is  that  of  a  man  threatened 
with  melanchoHa,  who  has  the  prehminary  symptoms  of  sleep- 
lessness, depression  of  spirits,  want  of  interest  in  anything, 
and  irritabihty  with  fears  and,  perhaps,  suspicions  of  all  sorts 
— who  has,  in  fact,  the  general  symptoms  of  brain  exhaustion. 
In  addition  to  the  rest,  the  exercise,  the  change,  the  fresh  air, 
the  fattening  easily  digested  food,  the  tonics  and  nerve  stimu- 
lants, and  the  walking  we  prescribe  for  such  a  case,  we  are 
justified,  and  frequently  compelled,  to  try  a  hypnotic,  if  fresh 
air  and  fatigue,  baths,  hot  and  cold,  modified  massage  or  warm 
bottles  to  abdomen  do  not  restore  the  sleep.  I  am  not  in 
favour  of  opium  for  such  a  case  in  however  small  doses, 
because  my  experience  is  that  it  diminishes  the  appetite,  and 
the  patient  does  not  gain,  but  tends  to  lose  in  weight,  while 
a  habit  and  a  craving  are  apt  to  be  set  up.  But  competent 
and  experienced  physicians  in  Germany,  France,  and  in  this 
country  use  opium  or  morphia  in  small  doses  in  such  cases, 
and  commend  it  highly.  They  say  it  promotes  the  nutrition 
of  the  brain,  soothes  mental  depression,  and  causes  sleep. 
Chloral  I  once  beheved  in  far  more  strongly  than  1  do  now. 
It  is  a  drug,  the  prolonged  use  of  which  in  some  cases  certainly 
tends  toward  tliinness,  toward  a  haggard  look  in  the  morning. 


SUMMARY   OF   TREATMENT   OF   INSANITY.  707 

and  toward  diminished  mental  inhibition,  as  shown  by  a  habit 
and  craving  for  its  continued  use.  Combined  with  the 
bromides,' in  15  or  20  grain  doses,  it  is  a  good  hypnotic  for 
short  periods,  especially  in  alcoholism. 

Paraldehyde.— Th-Q  drug  I  have  used  most  extensively  for 
the  past  nine  years,  and  like  far  better  than  any  other  pure 
hypnotic  I  have  ever  tried,  is  paraldehyde.  This  is  so 
valuable,  so  reliable,  and  so  free  from  risks,  near  or  remote, 
that  I  think  it  cannot  be  too  widely  known  by  the  profession. 
It  is  mainly  a  pure  hypnotic,  though  I  have  lately  seen  it 
recommended  in  small  doses  as  a  stimulant,  and  for  the 
vomiting  of  pregnancy.  It  acts  so  quickly,  that  often  the 
patient  is  sound  asleep  in  five  minutes  after  getting  the  dose. 
Out  of  hundreds  of  cases  in  which  we  have  used  it  here  it 
caused  sickness  in  only  a  few,  headache  and  disagreeable 
feelings  in  a  few,  a  general  "  discomfort "  in  one,  or  diarrhoea 
and  sickness  in  a  very  few.  It  does  not  interfere  with  the 
appetite  for  food  next  morning,  nor  ordinarily  disturb  the 
stomach  or  bowels.  After  a  paraldehyde  sleep  there  is  no 
headache,  no  lassitude,  and  several  sane  patients  to  whom  I 
have  given  it  have  said  that  even  the  refreshed  comfortable 
feehng  they  have  after  natural  sleep  is  present  after  it.  That 
seems  too  good  to  be  true  in  very  many  instances.  I  have  no 
behef  in  any  drug  sleep  being  quite  equal  to  natural  sleep,  in 
being  "  Nature's  sweet  restorer."  I  am  satisfied  of  this  im- 
portant fact,  however,  in  regard  to  paraldehyde,  that  while 
the  first  part  of  the  sleep  after  a  dose  is  drug  sleep,  this  passes 
gradually  into  what  is  really  natural  slumber.  In  fact,  it  puts 
to  sleep,  and  nature  continues  the  slumber.  Another  fact  of 
perhaps  greater  importance  still  is  this,  the  use  of  paraldehyde 
for  a  time  will,  in  some  cases,  restore  the  sleep-habit  of  brain, 
and  its  use  can  then  be  discontinued  readily,  and  with  no  felt 
want  and  craving  by  the  patients.  It  is  of  no  use,  but  the 
contrary,  given  through"  the  day  as  a  sedative.  It  seems  to 
act  on  the  very  highest  cortical  cells,  and  not  on  the  motor 
areas,  cortical   or  basal.     In  cases  of  mania   I   often  add  a 


708  SUMMARY   OF   TKEATMEXT   OF   IXSAXITY. 

draclirQ  of  one  of  the  bromides  to  the  dose  at  bedtime,  and 
in  very  acute  and  restless  cases  a  drachm  of  "bromidia." 
It  sometimes  excites  when  given  in  too  small  doses.  Its 
nauseous  taste  is  the  worst  thing  about  it 

The  proper  dose  of  paraldehyde  varies  enormously  according 
to  the  case.  Generally,  I  begin  with  40  minims  or  a  drachm,  . 
and  go  up  to  2  drachms  in  ordinary  cases.  In  very  many 
cases  of  confirmed  insomnia,  in  melanchoha,  and  in  acute 
mania,  I  have  given  3  and  even  4  drachms,  and  in  one  case 
6  drachms.  I  had  a  general  paralytic  patient  who  took  4 
drachms  every  night  for  a  fortnight.  A  lesser  dose  did  not 
cause  sleep.  Here  we  commonly  give  it  mixed  with  tincture 
of  quillaya  and  a  few  drops  of  chloric  ether  in  cinnamon 
water.  Its  bad  taste  cannot  be  quite  got  over,  however,  and 
patients  always  smell  of  it  for  twenty-four  hours  after  the 
last  dose; 

I  do  not  knoAv  how  much  would  be  a  poisonous  dose,  but  a 
nurse  by  mistake  once  gave  a  patient  of  mine,  a  small-sized 
woman  in  weak  health,  an  ounce,  with  the  result  that  she 
slept  a  stertorous  sleep  for  twelve  hours,  the  heart's  action 
not  being  interfered  with,  nor  the  reflexes,  but  rousing  and 
cofi"ee  on  several  occasions  during  the  night  only  very  par- 
tially brought  her  to  consciousness  whOe  under  its  influence. 
She  seemed  none  the  worse  afterwards. 

I  have  never  seen  paraldehyde  afi'ect  the  heart's  action  in 
any  way  except  to  strengthen  it  shortly  after  being  given.  I 
look  on  its  action  as  being  in  some  respects  half-way  between 
that  of  ether  and  alcohol,  but  with  a  far  more  decided  hypnotic 
effect  than'  either. 

I  have  had  many  cases  in  which  its  nightly  use  for  periods 
of  from  one  week  to  sis  has  been  foUoAved  at  once,  on  its 
being  stopped,  by  a  restoration  of  the  natural  sleep-habit. 
The  first  case  of  that  kuid  I  had  was  a  recent  but  very  marked 
one  of  suicidal  melancholia  with  restlessness  in  a  woman  at 
the  chmacteric,  who,  after  its  use  for  a  month,  at  once  began 
to  sleep  soundly  for  six  hours  every  night,  and  soon  made  a 


SUMMARY   OF  TREATMENT   OF   INSANITY.  709 

complete  recovery.  The  nest,  and  the  most  remarkable  I 
have  yet  met  with,  was  one  of  suicidal  melancholia  with  great 
impulsiveness,  who  had  not  slept  naturally  for  more  than  an 
hour  or  two  at  a  time  for  two  years.  As  she  required  a 
special  night  attendant,  I  knew  the  facts  accurately.  She  was 
put  on  paraldehyde  in  drachm  doses  every,  night.  •  Tliis  dose 
needed  to  be  doubled  to  get  seven  hours'  sleep.  This  was 
continued  every  night  for  six  weeks.  She  gained  in  weight, 
and  took  her  food  well  during  that  time.  It  was  then  stopped, 
and  the  patient  at  once  began  to  sleep  naturally,  has  never 
needed  a  draught  since  for  a  period  now  of  eighteen  months, 
and  very  soon  we  were  able  to  discontinue  the  special  night 
attendant.  Such  a  case  makes  a  very  deep  impression  on 
anyone  who  has  the  heavy  responsibility  of  treating  it.  The 
result  is  in  accordance  with  the  physiology  of  the  brain  so  far 
that  we  know  that  habits  and  "periodicities"  are  normal 
characteristics  of  its  functions  that  can  often  be  broken  or 
restored  by  outward  conditions. 

There  are  some  cases  of  very  acute  mania  and  melancholia, 
and  especially  of  the  acute  excitement  of  general  paralysis, 
where  half-ounce  doses  will  not  procure  sleep,  and  I  commonly 
do  not  push  it  beyond  this. 

Sulplwnal} — Next  to  paraldehyde,  and  many  physicians 
would  place  it  before  that  drug,  comes  sulphonal  as  a  hypnotic. 
In  addition  to  its  sleep-producing  effect,  sulphonal  acts  very 
markedly  as  a  sedative  and  motor-depressant,  and  can  be 
used  during  the  day  for  those  effects.  Its  action  is  entirely 
different  in  many  ways  from  paraldehyde.  It  takes  from 
an  hour  to  two  hours  instead  of  five  minutes  to  act.  Its 
effects  last  often  for  two  days  and  nights  instead  of  one  night. 
It  often  causes  giddiness  and  unpleasant  sensations  in  the 
morning.  It  should  be  used  in  doses  of  from  10  to  40  grains, 
with  a  very  rare  use  of  60  grains.     It  should  be  given  at  least 

^  I  have  not  had  the  same  experience  of  trional  as  of  sulphonal,  but 
then'  effects  are  very  analogous,  and  in  one  or  two  cases  trioual  seems  to 
act  as  the  better  hypnotic.     Its  dose  is  about  15  grains. 


710        '      SUMMARY   OF   TREATMENT   OF   INSANITY. 

one  hour  "before  bedtime  if  used  as  a  hypnotic.  It  is  best 
given  in  hot  milk  or  in  jelly,  not  being  soluble  to  any 
extent. 

The  kind  of  cases  in  ^diich  it  acts  best  are  those  with  some 
motor  excitement,  restlessness,  noise,  and  general  troublesome- 
ness  of  management.  In  the  stage  where  the  patient  feels 
agitated  and  afraid  of  an  acute  attack  coming  on  I  have  over 
and  over  again  seen  its  use  produce  calm  and  comfort, 
apparently  arresting  the  attack  at  an  early  stage.  It  acts 
admirably  in  small  doses,  say  15  grains  t-wice  a  day,  in  senile 
restlessness  and  mild  excitement.  I  have  thus  kept  many 
such  cases  at  home,  soothing  gently  their  downward  path,  who 
would  have  had  to  be  sent  to  asylums.  It  acts  well  in  simple 
mania  with  restlessness,  but  fails  except  with  dangerous  doses 
in  very  acute  or  delirious  mania.  In  melancholia  -ndth  agita- 
tion it  subdues  the  motor  symptoms,  but  leaves  the  patient 
usually  more  depressed  in  mind.  It  stupefies  and  bewilders 
such  cases  too  much.  In  recurrent  cases  of  mania  and  foUe 
circulaire,  and  in  chronic  mania,  its  effects  are  admirable  and 
often,  as  I  have  already  pointed  out,  curative,  or  nearly  so. 
It  may  be  safely  used  in  moderate  doses  in  cases  with  organic 
brain  disease.  In  the  first  stage  of  general  paralysis,  with' 
intense  maniacal  excitement  and  impidsiveness,  I  have  used 
it  in  large  and  repeated  doses  with  the  efi'ects  "of  immediate 
quietude  and  manageability,  and  after  a  few  weeks  of  tliis,  the 
patients  were  found  to  have  passed  out  of  the  excited  stage 
into  that  of  the  quiet  of  the  second  stage.  Alcohohc  insanity 
is  often  controlled  and  cured  by  the  drug.  I  have  referred 
(p.  246)  to  its  remarkable  efi'ect  in  arresting  the  tendency  to 
mania  in  folie  circulaire. 

The  evil  effects  and  dangers  of  sulphonal  are  its  tendency 
to  accumulate  and  cause  a  drowsy  stuporose.  hebetude,  with  a 
collapsed  appearance  and  weak  pulse,  resembling  bromism, 
and  in  a  very  few  cases  to  cause  the  very  serious  and  danger- 
ous condition  of  hsematoporphyrinuria.  The  urine  ^  becomes 
1  Dr  Os^vald,  Ghcsgoiv  2Iedical  Jounial,  Dec.  1S94. 


SUMMAKY   OF   TEEATMENT   OF   INSANITY.  711 

bright  r6d,  and  the  patient  is  found  to  be  low,  exhausted, 
sometimes  paralysed,  and  often  vomits.  There  is  the  utmost 
risk  to  hfe.  We  as  yet  cannot  tell  why  this  condition  should 
occur.  It  should  always  be  kept  in  mind  as  a  possible  contin- 
gency.. In  moderate  doses  sulphonal  does  not  depress  the  vaso- 
motor tone  or  the  heart's  force  to  any  extent.  Its  use  should 
always  be  intermitted  for  a  day  or  two  once  a  week.  Fre- 
quently one  dose  every  other  night  will  produce  sleep  for  two 
nights  running.  In  mania  one  dose  twice  a  week  I  have 
known  to  keep  the  patient  manageable  till  the  .attack  ended 
in  its  ordinary  course.  It  does  not  excite  a  craving  for  its 
continuance,  and  it  does  not  prolong  the  brain  disturbance.^ 
The  use  of  other  mental  and  motor  sedatives  and  depres- 
sants during  the  day  in  those,  forms  of  mental  disease  charac- 
terised by  motor  excitement  is  a  still  more  difficult  problem 
than  the  use  of  hypnotics  at  night.  Such  a  use  is  far  more 
liable  to  abuse,  and  is  essentially  more  unphysiological.  The 
temptation  toward  such  a  use,  for  present  ends,  is  so  great 
without  reference  to  the  "  natural  course  "  of  the  case  toward 
recovery  that  we  need  to  be  very  careful  how  we  employ  them. 
The  former  heroic  doses  of  antimony,  digitahs,  and  of  opium, 
the  prodigious  douches  of  old,  we  have  now  almost  absolutely 
discarded.  We  see  plainly  that  the  motor  quiet  thus  obtained 
was  not  half-way  to  cure,  but  perhaps  part  way  to  death.  The 
questions  we  ask  now  are,  Can  we  conserve  strength  and  pre- 
vent exhaustion  and  death  through  over-motor  energy  by  the 
use  of  sedatives  ?  Can  we  take  off  the  keen  edge  of  the'  motor 
excitement,  so  that  some  patients  can  be  made  more  manage- 
able, and  be  treated  at  home.  Can  we  so  diminish  motor 
excitement  that  the  patients  can  be  safely  taken  out  to 
Avalk  and  work,  and  so  get  rid  of  part  of  their  spare  energy 
in  normal  ways?  Can  we  so  diminish  impulsiveness  that 
danger  to  the  patient  and  others  may  be  lessened  without 

^  See  two  admirable  papers,  one  by  Dr  J.  C.  Mackenzie  in  the  Journal, 
of  Mental  Science  for  Jan.  1891,  and  the  other  by  Dr  Carlyle  Johnstone 
in  the  same  Journal  for  Jan.   1892. 


712  SUMMAEY  OF   TKEATMENT   OF  INSANITY. 

interfering  with  recovery,  or  with  health  in  incurable  cases? 
Can  we,  during  special  paroxysms  and  bodily  diseases,  tem- 
porarily diminish  motor  action  with  safety  1  If  excessive 
motor  energy  is  generated  in  the  brain  cortex,  it  is  surely  a 
reasonable  hypothesis,  that  it  should  generally  get  its  natural 
outlet  in  muscular  action.  But  there  are  limits  to  all  excesses 
of  action.  If  antipyrin,  on  the  whole,  does  harm  in  an  ordi- 
nary case  of  pneumonia  with  a  temperature  of  103°  and  puts 
off  recovery,  it  does  not  foUow  that  it  or  a  cold  bath  does 
not  save  a  patient's  life  when  the  temperature  is  running 
above  106°.  Patients  sometimes  die  of  the  exhaustion  of  over- 
motor  excitement.  How  do  we  know  in  any  such  case  that 
if  over-exertion  had  been  controlled  by  drugs  or  mechanical 
restraint  for  a  few  days,  the  crisis  might  not  have  passed 
in  the  ordinary  "  course  of  the  case "  ? 

There  is,  in  my  opinion,  legitimate  scope  for  the  use  ot 
sedatives  and  motor  depressants  in  mental  diseases  both  from 
physiological  and  chnical  data.  Which  are  the  best  and 
safest  measures  and  drugs  to  use  ?  A  categorical  and  uncon- 
ditioned ansAver  cannot  be  given  to  this  question.  Of  one 
thing  I  am  quite  sure  from  my  experience  :  Do  not  use 
during  the  day  a  pure  hypnotic  like  chloral  or  paraldehyde, 
either  alone  or  in  combination,  as  a  sedative  or  motor  depres- 
sant.    That  is  the  weak  point  of  "  bromidia." 

Another  principle  which  I  laid  down  twenty  years  ago  I 
still  adhere  to — Use  the  bromides  frequently  in  combination 
with  nearly  all  sedatives  and  motor  depressants.  Tliey  make 
a  lesser  dose  of  the  latter  more  equably  and  more  safely 
effectual  as  compared  with  a  large  dose  given  alone.  They 
prolong  the  sedative  effect.  They  diminish  motor  reflex 
excitability  in  the  whole  of  the  motor  centres,  and  they  may 
be  said  to  strengthen  the  whole  function  of  inhibition  thereby. 
They  are  very  safe  and  do  not  tend  to  affect  nutrition,  but 
often  the  contrary. 

The  Bro7nides  and  Cannabis  Indica. — The  combination  of 
the  bromides  with  cannabis  indica,  which  I  recommended  in 


SUMMARY  OF   TREATMENT   OF  INSANITY.  713 

1868/  and  have  used  continuously  since,  I  still  think  one  of 
the  best  sedatives,  because  it  is  mild  in  general  effect,  and 
does  not  affect  the  nutrition.  Patients  often  gain  in  weight 
during  its  use,  they  can  work  and  walk  while  under  its  in- 
fluence, and  impulsiveness  of  all  kinds  is  diminished  by  it. 
My  original  experiments,  which  were  very  carefully  made, 
have  been  confirmed  in  the  main  by  a  very  large  subsequent 
clinical  experience.  Not  that  all  my  hopes  and  expectations 
of  twenty  years  ago  in  regard  to  the  curative  effects  of  this 
or  any  other  sedative  on  cortical  brain  excitement  have  been 
realised.  Few  men  have  had  to  treat  diseases  for  twenty 
years  who  are  not  at  the  end  of  the  time  more  sceptical  about 
drug  treatment,  and  more  inclined  to  trust  to  the  vis  medi- 
catrix  under  favourable  conditions  than  they  were  at  the 
beginning,  on  the  whole.  There  are  marked  exceptions,  no 
doubt,  and  the  use  of  this  combination  as  a  sedative,  motor 
depressant,  and  diminisher  of  reflex  irritabihty  in  mildly 
maniacal  cases,  in  certain  cases  of  acute  mania  with  hysterical 
symptoms  and  noise  in  women,  in  epileptic  mania  not  of  the 
unconscious  delirious  type,  in  chronic  mania  with  paroxysms 
of  exacerbation,  in  all  cases  of  brain  excitement  with  more  or 
less  regular  periodicity  of  symptoms,  and  in  many  cases  of 
suicidal  melancholia  characterised  by  motor  excitement  and 
homicidal  violence — in  all  these  I  have  used  this  combination, 
and  found  it  an  admirable  sedative  without  disturbance  of 
digestive  functions  and  without  loss  of  nutrition  in  a  very 
large  number  of  cases.  I  always  weigh  my  patients  while 
they  are  taking  any  sedative  or  hypnotic  drug,  and  if  there  is 
a  continuous  loss  of  body-weight  I  am  inclined  to  stop  the 
medicine  and  try  how  the  case  will  run  on  without  it.  I 
commonly  now  begin  with  10  minims  of  the  tincture  of 
cannabis  and  30  grains  of  one  of  the  bromides  for  a  dose, 
rising  to  45  minims  of  the  former  to  a  drachm  of  the  latter. 

1  "  The  Action  of  Narcotic  Medicines  in  Insanity,"  being  the  Fother- 
gillian  Prize  Essay  for  1872,  by  the  author,  Brit,  and  Foreign  Med. -Chir. 
Leview  for  1870  and  1871. 


714  SUMMARY   OF   TREATMENT   OF   INSANITY. 

I  commonly  add  some  aromatic  spirit  of .  ammonia  to  tlie 
mixture  as  a  cardiac  stimulant,  and  also  to  keep  the  resin 
more  in  solution.  The  most  alarming  symptoms  I  have  ever 
seen  after  its  use  in  large  doses  resulted  from  the  temporary 
failure  of  the  heart's  action  in  one  anaemic  case  of  chronic 
mania  after  a  drachm  dose  of  the  tincture  of  cannahis  with 
a  drachm  of  hromide,  and  in.  another  instance  from  a  semi- 
comatose condition  in  a  case  of  folie  circulaire,  during  the 
excitement  wliich  I  was  attempting  to  "  keep  in  check  "  hy  a 
continuous  use  of  the  mixture.  In  the  former  kind  of  case 
I  now  add  some  digitalis.  In  other  cases,  and  for  special 
indications,  I  am  in  the  habit  of  adding  the  ammoniated 
tincture  of  valerian  to  the  combination.  This  does  specially 
well  where  there  are  hysterical  symptoms.  I  sometimes  add 
a  little  lupuline,  hyoscyamus,  or  belladonna. 

•  The  cannabis  indica  often  increases  the  appetite  and  acts  on 
the  kidneys.  The  taste  of  this  mixture  is  very  bad,  however, 
and  we  often  have  much  difficulty  with  maniacal  and  sus- 
picious cases  on  this  account.  In  some  patients  a  few  doses 
^^tII  be  sufl&cient  for  the  purpose  we  aim  at,  in  other  cases  the 
drugs  have  to  be  given  for  weeks  and  even  months.  I  have 
certainly  kept  many  patients  out  of  asylums  by  its  use.  TVTien 
the  excitement  is  very  intense,  and  tending  toward  "  delirious 
mania,"  with  dry  tongue,  sordes,  and  repugnance  to  food,  then 
I  cannot  recommend  this  combination,  nor  indeed  any  other 
sedative,  hypnotic,  or  narcotic  drug.  Nursing,  stimulants, 
suitable  feeding,  tonics,  and  fresh  air  are  in  these  circumstances 
alone  to  be  rehed  on,  if  we  wish  our  patients  to  have  the  best 
possible  chance  of  recovery.  In  general  paralysis  and  the 
excitement  of  organic  brain  disease  I  have  often  seen  the  com- 
bination give  great  rehef  and  quietude  without  any  ill  effect. 

The  mental  results  were  the  following :  There  was  less 
sudden  impulsive  action,  the  constant  talking  got  less,  the 
tendency  to  shouting  was  lessened  or  stopped,  there  was  less 
resistiveness  to  control,  there  was  a  drowsy  quietude  induced. 
The  emotional  state  was  one  of  greater  happiness,  and  intellec- 


SUMMARY   OF  TREATMENT   OF  INSANITY.  715 

tually  there  was  less  suspicion.  In  some  cases  hallucinations 
of  hearing  abated.  In  many  cases  walking  and  working  could 
be  engaged  in.     Inhibition  was  improved. 

The  following  symptoms  should  in  my  judgment  make  us 
hesitate  to  use  the  combination  or  stop  its  use,  viz.,  a  very 
weak,  thready  pulse,  a  very  foul,  creamy  tongue  increasing 
under  the  use  of  the  drugs,  a  dry  tongue  and  mouth,  an 
increase  of  motor  paralysis,  a  difficulty  in  equilibration  and 
walking,  a  tendency  to  stupor,  very  cold  extremities  and 
pinched  face,  as  if  the  general  nervous  and  vital  energy  was 
very  low  and  diminishing. 

Hyoscine. — If  a  pure  motor  depressant  is  indicated,  there  is 
no  doubt  that  hyoscine  is  the  best  drug  to  get  the  effect  of 
simple  motor  quietude.  I  have  many  cases  of  mania  where 
the  chief  symptoms,  and  by  far  the  most  troublesome,  are 
excessive  restlessness,  shouting,  tearing,  violence,  and  motor 
impulsiveness  of  all  kinds.  All  the  morbid  energising  of  the 
cortex  seems  in  such  cases  to  be  concentrated  in  the  motor 
centres.  Such  patients  are  always  troublesome,  sometimes 
dangerous  to  others,  and  many  of  them  tend  to  exhaust  their 
strength  to  a  dangerous  extent.  J^ow  if  any  such  case  is  in 
strong  and  vigorous  general  bodily  health,  and  has  a  sound 
heart,  hyoscine  may  be  tried  hypodermically  in  small  doses 
of  2^  gr.  carefully  watched,  and  going  up  to  g^  gr.  It  is,  so 
far  as  I  have  yet  used  it,  a  safe  and  a  moderate  depressant  of 
voluntary  motion,  without  narcosis  or  much  mental  confusion 
or  drowsiness.  So  far  as  I  have  yet  observed  its  effects,  it  is 
the  best  drug  for  this  special  effect.  It  has  not  in  my  cases 
affected  the  appetite,  nor  depressed  the  heart's  action  unduly, 
except  in  one  case  when  -,^  gr.  produced  alarming  stupor.  I 
must  say  I  have  been  afraid  to  push  it  in  very  restless  and 
violent  cases.  Several  strong  persons  of  this  kind  labouring 
under  acute  mania  resisted  ^  gr.,  and  I  was  afraid  to  push  it 
further  after  my  experience  of  hyoscyamine — an  altogether 
dangerous  drug.  I  should  give  it  very  guardedly  indeed  in 
general  paralysis  or  in  any  case  in  which  I  suspected  organic 


716  SUMMAEY   OF  TREATMENT   OF  INSANITY. 

brain  disease.  The  great  facility  of  its  hypodermic  use  makes 
it  suitable  for  emergencies,  and  where  the  patient  will  not  take 
a  drug  by  the  mouth. 

There  are  other  drugs  of  this  nature  at  our  disposal.  Chloral- 
amide,  urethan,  croton-chloral,  monobromide  of  camphor  and 
lupuline  are  all  mild  and  useful  hypnotics  and  sedatives. 

I  shall  conclude  with  a  few  principles  of  general  appHcation  : 

1.  Make  up  your  mind  clearly  from  the  symptoms  present 
whether  your  patient  needs  a  pure  hypnotic,  a  general  nervous 
sedative,  or  a  simple  motor  depressant  before  you  use  any  of 
these  drugs. 

2.  Use  all  such  drugs  experimentally  in  each  case  at  first, 
and  watch  their  effects  not  only  on  the  higher  nervous 
functions,  but  on  all  the  organs  and  their  functions ;  and  on 
the  general  organism. 

3.  Even  where  there  is  sleep  and  quiet  produced  for  the 
time  with  no  apparently  bad  results,  look  to  the  general 
feeling  of  bien-etre,  the  recuperative  energy,  the  expression  of 
face  and  eyes  after  their  use,  and  see  if  there  is  any  undue 
reaction  as  if  some  energy  that  must  have  an  "  outlet "  were 
merely  being  "  suppressed  "  for  the  time  being. 

4.  Stop  using  such  drugs  as  soon  as  possible,  trying  experi- 
mentally how  the  patient  gets  on  without  them. 

5.  Keep  asking  in  every  case — "  Are  we  sacrificing  in  any 
degree  the  highest  function  of  mental  inhibition  by  their  use  1 " 

6.  Never  omit  general  measures  for  the  restoration  of  the 
health,  nutrition,  and  higher  nervous  functions  while  you  use 
such  remedies.     Keep  weighing  your  patients  regularly. 

7.  Paraldehyde  is  the  purest  and  least  harmful  hypnotic 
yet  introduced  when  the  insomnia  is  marked  and  intractable. 
Urethan  and  chloralamide  cannot  conipare  with  it.  Opium, 
and  chloral  have  special  dangers  and  disadvantages. 

8.  Sulphonal  is  a  safe  and  excellent  hypnotic  and  sedative 
as  well  as  a  motor  depressant.  It  seems  to  have  a  larger  field 
of  application  than  almost  any  of  this  class  of  drugs  in 
mental  disease.     Trional  is  very  similar  in  its  effects, 


SUMMAKY   OF   TKEATMENT  OF   INSANITY.  717 

9.  Use  the  bromides  as  accentuators  and  prolongers  of  the 
effects  of  other  drugs,  and  in  order  to  be  able  to  employ 
smaller  'doses  than  otherwise. 

10.  A  combination  of  cannabis  indica  and  the  bromides  is 
one  of  the  most  useful  and  least  harmful  of  general  sedatives. 

11.  Hyoscine  is  the  best  pure  motor  depressant,  and  its  easy 
hypodermic  use  makes  it  very  convenient  where  the  patient 
refuses  to  take  medicines  by  the  mouth ;  but  it  needs  care. 

12.  We  should  never  deeply  narcotize  an  insane  patient  or 
one  threatened  with  mental  disease. 

13.  It  is  often  as  dangerous  to  use  mere  anodynes  by  the 
mouth  or  subcutaneously  to  relieve  mental  pain,  as  to  subdue 
bodily  pain  by  these  means  only,  perhaps  more  so. 

14.  It  is  generally  far  better  therapeutics  to  enable  your 
patient  to  bear  his  mental  pain  and  the  effects  of  his  insomnia 
by  improving  his  general  nervous  tone  and  the  nutrition  of 
his  brain  and  body,  than  merely  to  produce  quiet  and  sleep 
by  drugs. 

15.  It  is  commonly  a  safer  thing  for  the  patients,  and 
tends  more  toward  natural  recovery  from  his  disease,  to 
provide  a  physiological  outlet  for  morbid  motor  energy,  than 
merely  to  depress  it  directly  by  drugs. 

16.  It  is  almost  always  preferable  to  treat  cortical  exhaus- 
tion, irritability,  and  undue  reflex  excitability  by  alternate 
rest  and  exercise,  and  by  improving  the  fattening  and  nutri- 
tion of  the  body,  than  by  continuous  sedatives,  the-  great  ex- 
ceptions being  the  treatment  of  epilepsy  and  convulsive 
affections  by  the  bromides. 

17.  The  use  of  a  course  of  thyroid  extract,  given  in  60 
grain  doses  a  day,  to  produce  a  short  five  or  six  days'  fever, 
as  recommended  by  Dr  Lewis  Bruce  (see  pp.  191,  292),  is  a 
most  powerful  therapeutic  means  in  many  cases.  No  case 
should  be  allowed  to  become  incurable  without  a  trial  of  this 
method. 


INDEX 


Acute  mania,  159. 

Acute  dementia,  304,  319. 

Adolescence,  psychology  of,  589 ; 
insanity  of,  595  ;  mortality  in, 
608  ;  recoveiy,  signs  of,  in,  608  ; 
symptoms  of,  605  ;  treatment, 
600  ;  psychoses  of,  603. 

Affections  cooled  by  insanity,  166. 

Age  at  which  insanity  occurs,  210, 
and  Plate  V. 

Ague,  insanity  from,  659. 

Alcohol  a  cause  of  insanity,  480. 

Alcoholic  insanity,  479  ;  degenera- 
tion, 489. 

Alcoholism,  acute,  481  ;  chronic 
486. 

Alimentation  psychologically  con- 
sidered, 3. 

Alternating  insanity,  218. 

Alternation  in  insanity,  239. 

Amenorrhoeal  insanity,  521. 

Amentia,  10,  283. 

Amusement,  700. 

Anaemia  in  insanity  of  lactation, 
561. 

Anaemic  insanity,  650  ;  brain,  505. 

Animal  food  :  its  effects  on  neurotic 
children,  215,  601. 

Animal  impulse,  348. 

Aphasia  and  insanity,  423. 

Arnold,  post-febrile  insanity,  657.  . 

Arteries,  lesions  of,  in  brain  syphilis, 
468,  and  Plate  VII. 


Asthma,  insanity  of,  656. 
Atkins,  Dr,  667. 

Baillarger  first  described  circular 
insanity,  220. 

•  Ball,  Prof.  B.,  197. 

Baths  in  melancholia,  131. 

Baths,  hot,  in  mania,  75,  193  ; 
Turkish,  in  melancholia,  131.  • 

Begbie,  Dr  Warburton,  477,  655. 

Bell,  Dr  Luther,  171,  197. 

Belladonna  as  a  sleep  producer, 
217. 

Benedikt  on  the  brains  of  criminals, 
331. 

Bird,  G.,  on  oxaluria,  655. 

Blandford,  Dr  G.  Fielding,  196 
399. 

Blistering  in  mania,  191. 

Boils  in  mania,  191. 

Brain,  anfemic,  505,  650. 

Brain,  functions  of,  as  related  to 
mental  diseases,  13-19. 

Broadhnrst,  463. 

Bromides  in  mania,  178  ;  in  circular 
insanity,  245  ;  in  epilepsy,   452 
456  ;  as  hypnotics,  217  ;  as  seda- 
tives, 712. 

Bright's  disease,  insanity  in, 
653. 

Brown,  J.  J.,  86,  111  ;  a  new  lesion 
in  acute  mania,  195,  and  Plate 
II.  figs.  2,  4  ;  on  lesions  in  senile 


720 


INDEX. 


dementia,     644  ;     on    syphilitic 

arteritis,  470. 
Brown,  Dr  R.,  204. 
Bruce,  Dr  Lewis,  191,  292,  454. 
Bucknill  and  Tuke  on  post-febrile 

insanity,  659. 
Bucknill,  Dr  J.  C„  196. 
Burton,  127. 
Buzzard,  Dr  T.,  463. 

Cadell,  Dr,  his  case  of  syphilitic 
insanity,  465. 

Campbell,  Dr  J.  A.,  cases  of  visceral 
melancholia,  59. 

Camphor  as  a  sleep  producer,  178, 
217. 

Cat,  maternal  instinct  in,  336. 

Cannabis  Indica  in  melancholia,  89, 
132  ;  in  mania,  178  ;  in  alternat- 
ing insanity,  245  ;  as  sedative, 
712. 

Certificates  of  lunacy,  675  ;  for 
Curator  Bonis,  679. 

Certificates  for  treatment  in  private 
houses,  673. 

Certificates  of  sanitj^,  677. 

Chancery,  affidavits  for,  678. 

Children,  insanity  in  sensitive,  30, 
133,  138,  583. 

Chloral  as  a  sleep  producer,  217, 
706 ;  use  and  dangers  of,  in 
mania,  176  ;  insanity  from  use 
of,  490. 

Chorea,  its  connection  with  rheu- 
matism, 493  ;  delirium  of,  501. 

Choreic  insanity  in  early  youth, 
501  ;  its  epidemic  forms,  502 ; 
prognosis,  501  ;  treatment,  502. 

Christison,  Sir  E..,  267. 

Circular  insanity,  218  ;  causes  of, 
241  ;  duration '  of,  225-235  ;  fre- 
quency, 242  ;  its  nature,  220  ; 
pathology,  248  ;  symptoms,  235  ; 
treatment,  244  ;  termination, 
242. 


Clark,  Campbell,  his  case  of  hydro- 
cephalic idiocy,  302,  316,  369, 
560  ;  diabetic  insanity,  653. 

Classification  of  insanity,  10,  12. 

Climacteric  insanity,  610  ;  suicidal 
longings  in,  613  ;  pathological 
appearance  in,  618  ;  prognosis  in, 
620  ;  statistics,  620  ;  symptoms, 
611. 

Climacteric,  psychology  of,  611. 

Climacteric  in  man,  616  ;  in  woman, 
611. 

Communicated  insanity,  373. 

Competitive  examinations,  mischief 
from,  134. 

Congestion  of  brain  in  acute  mania, 
194,  and  Plate  IV. 

Conium  in  acute  mania,  178. 

Connubial  affection  altered  in  cli- 
macteric insanity,  613. 

Conscience  a  brain  quality,  370. 

Consciousness,  lost  in  mania,  162  ; 
in  epilepsy,  448 ;  in  stupor, 
308. 

Convolutions,  their  structure  and 
function,  14  ;  supply  of  blood  to, 
4,  18. 

Convulsive  melancholia,  95. 

Craving  for  stimulants  in  melan- 
cholia, 119. 

Cresswell,  Sir  Cresswell,  675. 

Cretinism,  303. 

Croom,  Dr  Halliday,  on  perversions 
of  appetites  during  menstruation, 
521,  522. 

Curator  Bonis,  appointment  of, 
679. 

Cyanosis,  insanity  of,  656. 

De  lunatico  inquireiido,  678, 
Decoration,  insane,  254. 
Deaf-mutism  a  hereditary  neurosis, 

303. 
Delirium  in  young  children,  666. 
Delirium  tremens,  21,  481. 


INDEX. 


721 


Delusions  of  melancholia,  list  of, 
79  ;  in  idiots,  252. 

Delnsions,  •  sane  and  insane,  251; 
insane  defined,  252  ;  their  legal 
importance,  273  ;  should  be 
tested,  22. 

Delusional  mania,  197. 

Delusional  melancholia,  56. 

Dementia,  278  ;  its  varieties,  283 
alcoholic,  488  ;  organic,  283,  418 
primary,  295  ;  secondary,  283 
senile,  621  ;  prognosis  in,  288. 

Demonomania,  73. 

Denman,  Lord,  680. 

Deprivation,  idiocy  by,  302 ;  in. 
sanity  by,  662. 

Desquamation,  118. 

Destructive  impulse,  357. 

Diabetic  insanity,  651. 

Diabolic  possession,  superstition  of, 
72. 

Diathesis,  the  insane,  373  ;  doc- 
trines of,  2. 

Diet.  See  Animal  Food  ;  in  melan- 
cholia, 126  ;  in  circular  insanity, 
244. 

Dietetic  management  of  the  nisus 
generativus,  539. 

Dipsomania,  359. 

Dissolution,  17. 

Dowse  on  prevalence  of  syphilis, 
463,  464. 

Drummond,  Dr,  403. 

Duncan, Dr  Matthews,  ou  fecundity, 
589. 

Duret,  643. 

Education  of  girls,  578  ;  of  neurotic 

children,  688. 
Eggs  in   the    treatment   of    acute 

mania,  181. 
Electricity  in  stupor,  292,  315  ;  in 

detecting  feigned  insanity,  686  ; 

delusions  of  being  tortured   by, 

70. 


Eliot,  George,  592. 

Elkins,  Dr  F.  A.,  352,  661,  697. 

Enfeeblement,  morbid,  278. 

Epileptic  insanity,  434  ;  counter 
irritations  in,  454  ;  hallucinations 
in,  446,  447  ;  pathology,  445, 
449  ;  prevalence  of,  455 ;  religious 
emotionalism  in,  439,  440  ;  sui- 
cidal impulses  in,  446  ;  treatment 
of,  452. 

Epileptic,  suicide  of  an,  448. 

Epileptics,  criminal,  438. 

Epileptiform  melancholia,  95  ;  im- 
pulse, 348  ;  convulsions  in  general 
paralysis,  392. 

Epilepsy,  pathology  of,  450  ;  vacuo- 
lation  of  nucleus  in,  Plate  IX., 
451  ;  compatible  with  sanity, 
435  ;  masked,  205,  437. 

Epithelial  granulations  in  ven- 
tricles, 409,  and  Plate  II.  fig.  3. 

Ergot  in  melancholic  stupor,  315. 

Erotomania,  337. 

Evolution,  17. 

Esquirol's  classification,  7,  160. 

Exaltation,  physiological,  137. 

Examining  patients,  rules  for,  19. 

Excited  melancholia,  81. 

Expression  of  face  in  insanity,  167. 

Fah-et  on  circular  insanity,  220. 

Fattening  an  adolescent,  601. 

Feeding,  forcible,  107,  698. 

Fears,  morbid,  49,  265. 

Ferrier  on  brain  localisation,  70, 
164,  378. 

Flesh  meat.     See  Animal  Food. 

Folic  a  deux,  373. 

Folic  a  double  forme,  218. 

Folic  circulaire,  218  ;  commence- 
ment of,  242 ;  termination  of,  242  ; 
treatment  of,  244  ;  pathology  of, 
248. 

Folic  raisonnante,  158,  221. 

Food,  697. 

2z 


722 


INDEX. 


Friends,  Society  of,  insanity  in, 
599. 

Garrod,  Dr  A.  B.,  504,  656. 

General  paralysis,  definition  of,  378; 
developmental,  401  ;  etiology  and 
distribution,  403, 417 ;  pathology, 
404,  and  Plates  I.,  II.,  VIII., 
XIII.,  XIV.,  and  XV  ;  stages  of, 
379  ;  varieties,  pathological,  388  ; 
varieties,  symptomatological ,  390 ; 
prevalence  and  ages,  417,  and 
Plate  V.  ;  its  nature,  414. 

Goltz,  Prof.,  14. 

Gouty  insanity,  503. 

Gowers,  Dr  W.  R.,  452. 

Greenlees,  Dr  T.  D.,  414. 

Gudden,  Prof.  V.,  409. 

Gull,  Sir  Wm.,  663. 

Hsematoma  auris,  95,  386,  595. 

Hsematoporphyrinuria,  71. 

Hallucination,  a,  defined,  164. 

Hemiplegia,  420  ;  alternating, 
85. 

Hereditary  tendency,  2  ;  of  melan- 
cholic diathesis,  122. 

Heubner,  643. 

Hitzig,  164,  378. 

Home  treatment  expensive,  24  ;  its 
advantages,  24. 

Homicidal  mania,  206  ;  melan- 
cholia, 102  ;  impulse,  349. 

Howden,  Dr  J.  C,  439. 

Howe,  Dr,  303. 

Hutchinson,  Jonathan,  463. 

Hygiene  in  neurotic  children, 
688. 

Hyoscyamus  as  a  hypnotic,  216. 

Hyoscine,  132,  178,  715. 

Hyperkinesia,  327. 

Hypnotics  in  insanity,  176,  701. 

Hypnotism,  129. 

Hypochondria,  30. 

Hypochondriacal  melancholia,  47. 


Hysterical  insanity,  527  ;  statistics 

of,  530. 
Hystero-epilepsy,  528. 

Idiocy,  definition  of,  295  ;  by  de- 
privation, 302  ;  eclampsic,  299  ; 
epileptic,  300  ;  genetous,  298  ; 
hydrocephalic,  302  ;  inflamma- 
tory, 301  ;  microcephalic,  301  ; 
paralytic,  300  ;  traumatic,  301 ; 
460. 

Illegitimacy,  a  cause  of  puerperal 
insanit}',  547. 

Illusion,  an,  defined,  164. 

Imbecility,  295  ;  congenital,  296. 

Imperative  Ideas,  373. 

Impulse,  animal,  348  ;  destructive, 
357  ;  homicidal,  349  ;  insane, 
327  ;  suicidal,  354  ;  uncontrol- 
lable, 327. 

Impulses,  morbid,  339. 

Impulsive  insanity,  327  ;  a  remark- 
able case  of,  341. 

Incoherence  in  mania,  163,  165,  and 
Plate  III. 

Indecision,  morbid,  38. 

Influenza,  mental  relationships  of, 
660. 

Inhibitory  power  defective,  329. 

Inhibitory  insanity,  327. 

Inglis,  T.,  on  hystero-epilepsy  with 
insanity,  528. 

Insane  impulse,  327. 

Insanity  of  adolescence,  589  ;  alco- 
holic, 479  ;   amenorrhoeal,    521 
anajmic,    650  ;   of  asthma,  656 
of  Bright's  disease,  653  ;  of  car 
diac  disease,  656  ;  choreic,  493 
circular,  218  ;  climacteric,  610 
of  cyanosis,  656  ;  by  deprivation 
662  ;    diabetic,    651  ;    epileptic 
434 ;  of  exophthalmic  goitre,  664  ; 
feigned,   686  ;  gouty;  503  ;  hys- 
terical, 527  ;  inhibitory,  327  ;  of 
lactation,  560  ;   of  lead   poison- 


INDEX. 


723 


ing,  667 ;  masturbation,  531  ; 
metastatic,  656  ;  moral,  369  ;  of 
myxoedema,  662  ;  ovarian,  526  ; 
of  oxaluria,  655  ;  paral3'tic,  418  ; 
phthisical,  504 ;  phosphaturia, 
655  ;  post-connubial,  667  ;  post- 
febrile, 657  ;  of  pregnancy,  567  ; 
of  puberty,  577  ;  puerperal,  544  ; 
rheumatic,  493  ;  senile,-  621  ; 
syphilitic,  463  ;  traumatic,  458. 

Insomnia,  702,  706. 

Ireland,  "W.  W.,  277;  on  idiocy, 
295,  298,  301. 

Irritability  defined,  334. 

Jackson,  J.  Hughlings,  12,  32,  205, 
378  ;  on  syphilitic  insanity,  464  ; 
epileptic  insanity,  435. 

Jealousy,  insane,  267. 

Jones,  Dr  Bence,  656. 

Johnstone,  Dr  Carlyle,  664,  711. 

•Kahlbaum,  238. 
Kalmuck,  299. 
Katatonia,  238. 
Keith,  Dr  T,,  601. 
Kleptomania,  11,  337,  366. 
KrafFt-Ebing,  Prof.,  172,  197. 

Lactation,  insanity  of,  560  ;  prog- 
nosis, 566  ;  statistics  of,  563  ; 
symptoms,  561  ;  treatment,  563. 

Ladd,  Prof.,  17. 

Lancereaux,  464. 

Lawlessness,  organic,  331. 

Laycock,  T.,  on  organic  memory, 
163  ;  on  the  reflex  function  of  the 
brain,  .335  ;  on  general  paralysis, 
390. 

Laziness  often  a  disease,  44. 

Lead  poisoning,  insanity  of,  667. 

Lehmann,  656. 

Legal  views  about  insanity,  680. 

Lewis,  W.  Bevan,  32,  122,  196, 
■399,    402,    410,    411,    412,    413, 


450,    454,    491,    605,    637,    641, 

645. 
Locke,  John,  254. 
Lycanthropia,  337. 

Maclaren,  J.,  case  of  impulsive  in- 
sanity, 341. 

Mackenzie,  Dr  J.  C,  711. 

Macleod,  Dr  M.,  560. 

Macphail,  Dr,  284,  453. 

Major,  Dr  H.,  on  senile  brains, 
645. 

Mania,  8,  136  ;  h  potu,  488  ;  acute, 
159  ;  in  children,  138 ;  acute 
delirious,  162  ;  chronic,  197  ;  de- 
lusional, 197  ;  emotional  condi- 
tions, 211  ;  ephemeral  (transi- 
toria),  204 ;  homicidal,  206  ; 
simple,  142 ;  diagnosis,  271  ; 
definition  of,  140  ;  diet  in,  173  ; 
first  stage  of,  160  ;  second  stage 
of,  162  ;  pathology  of  chronic, 
198,  and  Plate  VIII.  fig,  2  ; 
prevalence,  210,  and  Plate  V,  ; 
delusions  in,  210  ;  prognosis  of, 
211  ;  terminations  of,  213  ;  pro- 
phylaxis in,  214 ;  treatment  of 
acute,  173,  179  ;  caused  by  a  new 
lesion,  195,  and  Plate  II.  fig.  2  ; 
periodic,  218  ;  recurrent,  218. 

Marriage  in  circular  insanity,  244  ; 
in  masturbational  insanity,  541  ; 
with  neurotic  persons,  687. 

Mansfield,  Lord,  680. 

Massage,  43. 

Masturbation,  insanity  of,  531  ; 
bodily  signs  in,  534  ;  bromides 
in,  540  ;  self-learned,  539  ;  treat- 
ment of,  539  ;  statistics  of,  541. 

Maudsley,  Dr  H.,  277,  373,  501, 
508,  659. 

Mechanical  restraint  in  mania,  170. 

Medico-legal  duties  of  medical  men 
in  mental  diseases,  669. 

Megalomania,  118,  253. 


724 


INDEX. 


Melancholia,  its  definition  and 
nature,  30  ;  in  children,  666  ; 
convulsive,  95  ;  delusional,  56  ; 
epileptiform,  95  ;  excited,  81  ; 
homicidal,  102 ;  hypochondriacal, 
47  ;  organic,  98  ;  resistive,  90  ; 
simple,  33  ;  suicidal,  102  ;  causa- 
tion of,  122  ;  bodily  symptoms  of, 
120  ;  prognosis  of,  47,  123  ;  pro- 
phylaxis, 133  ;  delusions  in,  79  ; 
religious,  72  ;  termination  of, 
124  ;  inception  of,  118  ;  preval- 
ence and  ages,  119,  and  Plate  V.  ; 
lesions  in  brain  in,  61,  69,  100, 
.  and  Plate  II.  fig.  1  ;  hereditary 
predisposition  in,  122  ;  treat- 
ment of,  125,  291. 

Melancholic  diathesis,  29  ;  persons, 
28. 

Melancholy  v.  melancholia,  30. 

Melancholy  hereditary,  29. 

Memory,  morbid,  164  ;  in  acute 
mania,  162. 

Mendel,  Prof.,  409. 

Menstruation,  insanity  from  sus- 
pended, 525  ;  in  acute  mania, 
189  ;  psychology  of,  521. 

Mental  conditions  liable  to  be  mis- 
taken for  insanity,  21. 

Merson,  Dr,  621. 

Metastatic  insanity,  656. 

Meynert,  82,  120,  409. 

Mickle,  Dr  J.,  131,  409. 

Middlemass,  Dr  J.,  387,  397,  405, 
410,  451. 

Mierzejewski,  412. 

Milk  in  melancholia,  127  ;  in  acute 
mania,  173 ;  in  adolescent  in- 
sanity, 601. 

Mitchell,  Sir  Arthur,  682. 

Moncreiff,  Lord,  680. 

Monomania  (mono-psychosLs),  8,  10, 
250  ;  of  grandeur,  253  ;  of  sus- 
picion, 264  ;  of  unseen  agency, 
260  ;  diagnosis  of,  271  ;  origin  of, 


272 ;  prognosis,  274 ;  prophylaxis, 
275  ;  treatment,  274. 

Moral  insanity,  369  ;  Prichard's, 
144,  221. 

Moreau  de  Tours  on  human  de- 
generation, 480. 

Morel,  12,  205,  339,  373,  480,  507. 

Morselli  on  suicide,  103,  106. 

Motor  depressants,  701. 

Mouth-openers,  108. 

Myxoedema,  662. 

N'arcotics,  in  melancholia,  131  ;  in 

mania,  176. 
Necrophilism,  337. 
Neuralgia  analogous  to  melancholia, 

7. 
Neurasthenia,  43. 
Neurosis,  insane,  11, 
Newington,  Hayes,  on  alternating 

hemiplegia,  85  ;  anergic  stupor, 

308 ;  mania  a  potu,  488  ;  syphilo- 

matous  insanity,  468. 
Nitrite  of  amyl  in  mania,  178. 
Nothnagel,  Prof.,  14. 
Nymphomania,  337. 

Obstinacy,  morbid,  in  melancholia, 

90. 
Old  maid's  insanity,  526. 
Opium  useless  in  melancholia,  131  ; 

and  in  mania,  176  ;  useful  against 

sleeplessness,  217,  706. 
Organic  dementia,  418. 
Organic  melancholia,  98. 
Oswald,  Dr,  710. 
Ovarian  insanity,  526. 
Oxaluria,  insanity  of,  655. 

Paraldehyde,  131,  706. 
Paralysis.     See  General  Paralysis. 
Paralysis  of  energy,  41  ;  of  feeling, 

43.' 
Paralytic  insanity,  418  ;  analogies, 

421  ;  causes,  420  ;  congestive  and 


INDEX. 


725 


epileptiform  attacks  in,  422  ; 
pathology  of,  432  ;  statistics, 
432  ;•  symptoms,  422. 

Paranoia,  158,  276,  376. 

Pathology  of  visceral  melancholia, 
60,  70,  and  Plate  II.  fig.  1  ;  Folie 
circulaire,  248,  and  Plate  VI,  ; 
general  paralysis,  404,  and  Plates 
I.  fig.  3  ;  VIII.,  XIII.,  XIV., 
and  XV.  ;  of  syphilitic  in- 
sanity, 469,  and  Plate  VII.  ;  of 
cells.  Plates  I.  fig.  1  ;  VIII.,  IX., 
XIII.,  and  XV.  figs.  6  to  10  ;  of 
vessels.  Plates  II.  fig.  4  ;  VIII. 
fig.  1  ;  IX.,  XIV.,  and  XV.  figs. 
1  to  5  ;  of  neuroglia,  Plates  VIII. 
fig.  1,  and  XIV,  fig.  2  ;  of  pia 
mater,  Plate  XIV.  fig.  1  ;  of 
epithelium,  Plate  II.  fig.  3  ;  of 
skull-cap,  Plate  VI, 

Periodicity  in  mental  diseases, 
220. 

Philipps,  Dr  Rees,  176, 

Phosphates  in  melancholia,  126. 

Phosphaturia,  insanity  of,  655. 

Phosphorus  in  mental  depression, 
126, 

Phthisica  spes,  507. 

Phthisical  insanity,  504  ;  pathology 
of,  513,  515  ;  prognosis,  518  ; 
statistics,  518  ;  symptoms,  509, 

Phthisis  common  among  the  in- 
sane, 506  ;  mental  condition,  517. 

Pia  mater  adherent  in  general 
paralysis,  407,  and  Plate  I, 

Pinel,  7, 

Plan.omania,  37, 

Podagrous  insanity.  See  Gouty  in- 
sanity. 

Post-connubial  insanity,  667. 

Post-febrile  insanity,  657. 

Pregnancy,  insanity  of,  567  ;  char- 
acter of,  568-570 ;  prognosis,  572  ; 
suicidal  tendency  in,  571  ;  statis- 
tics of,  571. 


Pregnancy,  its  psychology,  567  ; 
suicidal  tendency  in,  571. 

Prichard's  moral  insanity,  144,  221. 

Primare  Verriicktheit,  158,  376. 

Prout,  Dr,  655.     {See  Oxaluria.) 

Psychalgia,  8,  10. 

Psychlampsia,  10,  136. 

Psychocoma,  9,  11,  305. 

Psychokinesia,  10,  11,  327  ;  general, 
340. 

Psychology  of  menstruation,  521  ; 
of  adolescence,  589  ;  of  the  clim- 
acteric, 611  ;  of  old  age,  622. 

Psych  oneurosis,  10. 

Psychoparesis,  9,  11,  278. 

Psychorhythm,  8,  10,  218. 

Puberty,  the  period  of,  577  ;  in- 
sanity of,  577,  586. 

Puerperal  insanity  defined,  544  ; 
frequency,  554  ;  heredity  in,  554  ; 
pathology  of,  553  ;  prognosis  in, 
558,  559  ;  statistics,  554  ;  symp- 
toms, 545. 

Pyromania,  337. 

Quinine  in  melancholia,126,291, 553. 

Rayner  on  the  insanity  of  lead 
poisoning,  667. 

Reade,  463. 

Reasoning  insanity,  221. 

Relapses  in  insanity,  218. 

Religious  melancholia,  72. 

Reproduction  psychologically  con- 
sidered, 4,  580. 

Resistive  melancholia,  90. 

Responsibility,  legal,  333. 

Rest,  699. 

Reversion,  17. 

Restraint  in  mania,  170. 

Rheumatic  insanity,  493. 

Robertson,  A.,  on  the  insanity  of 
lead  poisoning,  667. 

Robertson,  DrG.  M.,  129,  140,  211. 

Robertson,  Dr  W.  P.,  387,  405,  451. 


726 


INDEX. 


Romanes,  Prof.  G.  J.,  17. 
Ronaldson,  Dr  Brace,  538. 

Satyriasis,  337. 

Savage,  Dr  G.  H,,  196,  197,  288, 
404,  667. 

Schroeder,  Van  der  Kolk,  12,  450, 
506. 

Sedatives,  701. 

Self-control,  sane  lack  of,  329. 

Senile  insanity,  621  ;  statistics  of, 
624  ;  hallucinations  of  hearing 
in,  637  ;  motor  restlessness,  626  ; 
pathology  of,  640  ;  prognosis  in, 
639  ;  treatment,  646. 

Senility,  psychology  of,  622. 

Sensibility  diminished  in  mania, 
169. 

Septic  inflammations  in  mania,  191. 

Septicfemia,  and  puerperal  insanity, 
554. 

Shaw,  Dr  Claye,  407,  417. 

Shower  baths,  291. 

Skae,  C.  H.,  case  of  trephining, 
274,  460. 

Skae,  Dr,  his  classification,  12,  434, 
526,  530,  657. 

Smith,  Willie,  the  homicide,  207. 

Somnambulism,  667. 

Spencer,  Herbert,  17,  32. 

Spider-cell,  411. 

Stephen,  Mr  Justice,  680. 

Stewart,  H.  G.,  on  monomania  of 
unseen  agency,  261  ;  on  delu- 
sional syphilitic  insanity,  467. 

Stewart,  Sir  T.  G.,  on  insanity 
from  Bright's  disease,  653. 

Stimulants  in  melancholia,  127. 

Strychnine  in  mania,  179  ;  in  melan- 
cholia, 126 ;  in  threatened  demen- 
tia, 291,  698. 

Study  of  mental  diseases,  13-24. 

Stupor  defined,  305  ;  varieties  of, 
309 ;  anergic,  317 ;  epileptic, 
324  ;  melancholic,  309  ;  paralytic, 


324  ;  secondary,  324  ;  causation 
of,  324  ;  prognosis  in,  326  ;  treat- 
ment of,  326  ;  pathology  of,  326. 

Suicidal  melancholia,  102;  impulse, 
354  ;  frequency  of,  112. 

Suicide,  case  of,  305  ;  a  determined, 
109  ;  in  an  epileptic,  448  ;  letter 
of  a,  108  ;  modes  of  committing, 
106. 

Sully,  J.,  164. 

Sulphonal,  132,  177,  246,  709. 

Suspicion,  monomania  of,  264. 

Sunstroke,  a  cause  of  insanity,  458. 

Sydenham  on  insanity  from  gout, 
503  ;  from  ague,  659. 

Syme,Prof.,  442. 

Symptomatological  classification, 
10. 

Syphilis,  its  prevalence,  464. 

Syphilitic  insanity,  463  ;  delusional, 
467  ;  secondary,  465  ;  sj-philo- 
matous,  468,  474  ;  vascular,  468  ; 
cephalalgia  in,  477  ;  pathology  of, 
469,  475 ;  prognosis  of,  479  ; 
treatment  of,  477. 

Temperaments,  doctrine  of,  2  ;  san- 
guine, 137. 

Temperature  in  insanity,  20  ;  in 
mania,  147,  169  ;  in  children, 
138  ;  in  puerperal  insanity,  556. 

Tests  of  insanity  made  by  lawyers, 
680. 

Thyroid  feeding,  191,  292,  664. 

Tracey,  Judge,  680. 

Traumatic  insanity,  458  ;  idiocy, 
460  ;  trephining  in,  459  ;  preva- 
lence of,  461. 

Treatment,  693. 

Trional,  709. 

Tuczek,  Prof.,  411. 

Tuke,  Dr  D.  Hack,  196,  306, 
659. 

Tuke,  Dr  J.  Batty,  302,  407,  409, 
417,  560,  564. 


INDEX. 


727 


Tumours    of  .brain   and    insanity, 

427. 
Turner,- Dr  John,  168. 
Twins    witli    hereditary    neurosis, 

215  ;  with  general  paralysis,  404. 
Typhomania,  197. 

Uncontrollable  impulse,  327. 

Vacuolation  of  nucleus  in  epilepsy, 
451,  and  Plate  IX. 

Vaso-motor  spasm,  102. 

Verriicktheit,  primare,  158,  376. 

Visceral  melancholia,  59  ;  pathol- 
ogy of,  60,  70,  and  Plate  II. 
fig.  1. 


Voisin,  Dr  A.,  409. 
Volitional  insanity,  327. 

Waller,  642. 

Wallis,  Dr  J.  A.,  454. 

Wiglesworth,  Dr  J.,  326,  560. 

Wilks  on  insanity  from  Bright's 
disease,  653  ;  on  syphilitic  affec- 
tions, 464. 

Will-making,  683. 

Wilson,  Dr  G.  R.,  403,  586, 

Yellowlees,  Dr  D.,  107  ;  his  case  of 
homicidal  mania,  207  ;  his  case  of 
somnambulism,  668. 


NEILL   AND  COMPANY,    PRINTEKS,    EUINBUIIGH. 


PLATE  I, 


THE  VERTEX  OF  THE  BRAIN  IN  ADVANCED  GENERAL  PARALYSIS. 
FRONTISPIECE,  FOR  DESCRIPTION  SEE  PAGE  IX, 


PLATE  II. 

Five  microscopic  drawings.  Fig.  1.  Cells  of  semilunar  abdominal 
ganglion  of  a  very  bad  case  of  visceral  melancholia,  in  a  condition  of 
o.trophy,  degeneration,  and  pigmentation.  This  patient  had  intense 
delusions  that  she  had  no  stomach,  and  that  her  bowels  wei-e  never 
moved.  She  had  no  appetite,  she  obstinately  refused  food,  and  died 
of  exhaustion,  though  regularly  fed  with  the  stomach  pump. 

Fig.  2  shows  a  new  lesion  of  the  brain  discovered  by  Dr  J.  J. 
Brown,  in  a  case  of  acute  mania  in  the  Royal  Edinburgh  Asylum  in 
1877.  This  is  a  section  from  a  convolution,  showing  its  free  surface 
at  upper  part  of  section,  from  which  the  pia  mater  had  been  re- 
moved, and  in  the  part  of  grey  substance  drawn  an  enormous 
deposit  of  a  new  substance,  taking  up  most  of  its  middle  layers.  It 
appeared  in  masses,  in  smaller  nuclei-like  bodies,  and  also  round  the 
vessels.  The  larger  cells  seen  in  the  inner  layers  of  the  grey  sub- 
stance were  somewhat  degenerated  and  atrophied,  their  processes 
having  disappeared. 

Fig.  3.  An  epithelial  granulation,  from  the  floor  of  the  fourth 
ventricle  of  a  case  of  advanced  general  paralysis,  showing  enor- 
mous proliferation  of  the  epithelial  cells.  There  is  one,  or,  at  the 
most,  two  normal  layers  of  delicate  epithelial  cells  in  this  position  ; 
but  as  seen  in  the  section  they  have  increased  greatly,  and  have 
altered  in  appearance.  At  the  summit  of  the  granulation  they  are 
roun'j,  at  its  base  flattened,  while  under  it  we  observe  a  sclerosed 
layer  of  nervous  tissue,  with  the  neuroglia  enormously  increased  in 
volume. 

Fig.  4.  A  small  artery  in  the  brain,  with  all  its  coats  enormously 
thickened,  separated  from  each  other,  and  its  lumen  almost  obliter- 
ated, as  found  in  some  cases  of  sypliilitic  insanity,  senile  insanity, 
and  other  forms  (after  Dr  J.  J.  Brown). 

Fig.  5.  A  portion  of  starved  and  atrophied  brain  substance,  from 
a  convolution  of  a  case  of  senile  insanity.  The  whole  substance  is 
loose,  recticulated,  and  almost  destitute  of  brain-cells  in  upper  part 
of  section,  with  only  the  packing  tissues  and  vessels  left. 


p.  729        PLATE  II. 


PLATE   III. 

Facsimile  of  a  letter  written  by  a  maniacal  patient,  showing  in- 
coherence, rapid  change  of  ideas,  delusions,  hallucinations  of  sight, 
an  insane  association  of  ideas,  and  an  insane  symbolism. 


p.  730       PLATE  m. 


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PLATE  IV. 

The  appearance  of  a  section  of  the  anterior  lobe  of  the  brain  in  a 
patient  who  had  died  of  the  exhaustion  of  acute  mania.     It  shows — 
a.  The  congested  grey  substance  of  the  convolutions, 
fc.    Congested  white  substance  near  grey  matter. 

c.  An  inner  ring  of  still  more  intense  congestion  along  the  line  of 
junction  of  the  grey  and  white  substances,  and  extending  into  the 
white  substance. 

d.  Limited  vaso-motor  areas  of  congestion  in  the  white  substance. 
This  is  a  type  of  the  irregular  vascularity  seen  in  the  brain  very 

commonly  in  acute  insanity,  indicating  probably  during  life  a  dis- 
turbed vaso-motor  condition,  which  is  a  necessary  accompaniment, 
and  probably  the  effect  of  the  cell  disturbance. 


PLATE   V. 

A  chart  showing  the  relative  prevalence  of  Melancholia  (thin 
line),  Mania  (thick  line),  and  General  Paralysis  (dotted  line)  in  the 
Royal  Edinburgh  Asylum,  and  the  age  at  which  those  three  con- 
ditions are  most  prevalent.  The  numbers  per  1000  of  the  total 
admissions  run  along  the  sides,  and  the  ages  along  the  top  and 
bottom  of  the  chart.  It  is  seen  that  most  cases  of  melancholia  occur 
between  35  and  40,  while  the  highest  number  suffering  from  mania 
occurred  between  20  and  25.  The  melancholic  line  keeps  high  all 
through  the  end  of  life.  General  paralysis  is  scarcely  found  at  all 
before  25,  reaches  its  acme  between  40  and  45,  and  is  scarcely  found 
at  all  after  57.  While  maniacal  conditions  rise  highest  as  adolescence 
is  completed  between  20  and  25,  they  rise  very  high  again  at  the 
period  when  melancholic  conditions  prevail  most,  between  35  and 
40  ;  that  is,  when  the  mental  and  moral  causes  of  insanity  are  most 
prevalent,  when  the  business  troubles,  domestic  worries,  the  afflic- 
tions, and  the  keen  competitions  of  life  are  most  common  or  most 
keenly  felt. 


732        PLi^TE    V. 


C  HART 


Showing  the  numbers  per  1000  of  Total  admissions, 
ind  the  A^es  of  996  cases  of  Mania,  535cases  of  Melancholia, 
ind  104  cases  of  General  Paralysis,  making  together  1635  cases 
)f  the   1778  Total  cases  admitted  into  the  Royal   Edinburgh 


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PLATE   VI. 

Great  thickening  of  skull-cap  anteriorly,  with  enormous  deposits 
of  new  osseous  tissue  in  an  irregularly  nodulated  way  on  the  inner 
table  of  skull,  in  a  case  of  alternating  insanity  of  over  twenty  years' 
duration.  This  seems  to  be  an  aggravated  example  and  type  of  what 
is  almost  universal  in  chronic  insanity  with  periods  of  excitement. 
It  is  a  proof  of  the  structural  effects  of  such  repeated  congestions  of 
the  branches  of  the  carotid  artery,  even  in  the  hardest  tissue,  and 
may  be  fairly  considered  to  be  of  the  same  nature  as  the  brain 
changes  in  the  same  cases,  which  are  not  so  evident,  but  are  no 
doubt  far  more  important.  The  atrophy  of  the  anterior  lobes  of 
the  brain  that  usually  accompanies  such  bony  thickenings  and 
deposits  probably  helps  their  growth,  they  being  thus  "compen- 
satory" to  some  extent,  like  the  increased  cerebro-spinal  iiuid. 


'p.  733        PLATE  VI. 


PLATE   VII. 

A  section  through  the  brain  of  a  man  who  had  laboured  under 
syphilitic  insanity  (the  third  or  vascular  form),  with  slow  arteritis 
affecting  the  vessels  supplying  the  anterior  and  part  of  middle  lobes 
of  one  hemisphere.  This  had  caused  slow  starvation  and  absorption 
of  nearlj'  all  the  white  substance  in  the  centre  of  those  lobes, 
leaving  the  grey  matter  of  the  gyri  almost  intact,  so  that  there  was 
a  sac  of  fluid  inside  with  the  convolutions  forming  its  walls.  The 
convolutions  looked  at  from  the  inside  are  quite  defined,  and  look 
as  if  the  white  substance  had  been  carefully  scraped  off  them. 
This  illustrates  the  greater  vascularity,  and  consequent  greater 
vitalitj%  of  the  grey  matter  as  compared  with  the  white,  as  well  as 
the  different  sources  of  the  chief  blood  supply  of  each. 


734        PLATE  VII. 


PLATE   VIII. 

Fig.  1.  Fresh  section  of  cortex  from  a  case  of  general  paralysis, 
stained  with  aniline  blue  black.  The  drawing  is  from  the  deepest 
layer  of  the  grey  matter.      x  300. 

a.  a.  Spider  cells  with  distinct  "vascular  processes"  v.  p.,  and 
numerous  very  fine  processes. 

Z).  h.  Degenerate  nerve-cells,  with  processes  of  spider-cells  passing 
near  them. 

c.  Small  blood-vessel  showing  proliferation  of  adventitial  nuclei 
and  irregularity  of  outline. 

d.  Nuclei  of  neuroglia. 

Fig.  2.  Fresh  section  of  inferior  frontal  convolution  from  a  case 
of  chronic  mania  of  thirty-five  years'  duration.      x  300. 

a,  a.  Nerve-cells  of  third  layer  showing  evidences  of  pigmentary 
degeneration.  Most  of  the  fine  processes  have  gone ;  in  some  the 
apex-process  also  has  disappeared.  There  is  a  great  increase  in  the 
pigment  granules  in  all  the  cells. 

h.  A  blood-vessel  showing  numerous  granular  deposits  of  pigment 
(c)  in  the  perivascular  space,  and  some  increase  in  the  adventitial 
nuclei. 

d.   Nuclei  of  neuroglia. 

Note. — This  and  Plate  IX.  were  di'awn  by  Dr  MidcUemass. 


p.  735        PLATE  VIII. 


X    300 


X    300 


GWaterston&Sons,  Ec 


PLATE  IX. 

Fig.  1.  Fresh  section  from  the  inf.  frontal  convolution  of  a  case 
of   epilepsy.       The   drawing   shows   the   cells   of   the   third   layer. 

X  300.  ^     ,  , 

a  a.  Nerve-cells  showing  distinct  vacuolation  of  the  nucleus. 
In  some  the  processes  are  still  present;  in  others  they  have 
degenerated. 

6.  A  small  blood-vessel. 

c.  Nuclei  of  neuroglia. 

Fig  2.  Fresh  section  of  Broca's  convolution  m  a  case  of  develop- 
mental epilepsy.— a.  Nerve-cell  showing  well-stained  nucleus,  with 
small  amount  of  protoplasm  round  it.  b.  Nerve  cell  showmg 
remains  of  apex-process  and  granules  of  pigment  in  protoplasm, 
c  Mass  of  cell-protoplasm  without  nucleus,  d.  Nucleus  of  nerve- 
cell,  apparently  destitute  of  protoplasm,     e.  Nucleus  of  neuroglia- 

cell.      X  300.  ^.  .         ^        ^     . 

Fig  3  A  nerve-cell  showing  granular  condition  of  protoplasm, 
collections  of  pigment  granules,  irregular  staining  of  nucleus,  and 
atrophy  of  protoplasm  and  processes.      x  650. 


p.  736        PLATE  IX. 


Fixi.  Z 


PLATE   X. 

Photographs  of  casts  of  palates  taken  from  patients  in  the  Royal 
Edinbui'gh  Asylum,  showing  the  three  standard  types  of  palate  I 
used  iu  my  investigations  into  the  condition  of  the  palate  among  the 
insane,  among  the  idiotic,  among  criminals,  and  among  the  general 
population. 

Also  showing  the  three  varieties  of  palate  in  adolescent  insanity. 

1.  "  Typical,"  with  line  of  teeth  and  arch  of  palate  both  approach- 
ing the  semi-circular. 

2.  "  Neurotic,"  witli  line  of  teeth  and  arch  of  palate  more  like 
the  Gothic  arch. 

3.  "Deformed,"  with  line  of  teeth  irregular  and  palate  arch 
V-shaped. 

4.  5,  and  6.  Palates  from  cases  of  adolescent  insanity,  illustrating 
strongly  "neurotic"  and  "deformed"  conditions. 


737        PLATE   X 


STANDARD   TYPES   OF   PALATE. 


2.  NEUROTIC, 


3.  DEFORMED, 


ADOLESCENT  INSANITY, 


4.  NEUROTIC, 


5.    DEFORMED, 


6,   DEFORMED, 

jjith   Central  Rii 


PLATE  XI. 
Sections— vertical  transverse  and  vertical  antero-posterior— of  the 
turee  types  of  palate. 

1.  Typical. 

2.  Neurotic. 
r>.  Deformed. 


p.  738        PLATE  XL 

SECTIONS    OF    STANDARD    PALATES 


TRANSVERSE 


NEUROTIC. 


DEFORMED. 


LONGITUDINAL, 


The  Soft  Palate  is  represented   by  a  dotted   line. 


PI,ATE   XII. 

Sections  of  palates,  vertical  transverse,  and  vei'tical  antero- 
posterior of  six  typical  cases  of  adolescent  insanity,  taken  by  Dr 
G.  R.  Wilson,  by  means  of  pieces  of  lead  moulded  to  the  shape  of 
the  palate  in  the  living  subject.  These  show  the  varieties  and 
gradations  in  the  shape  of  the  palate,  both  transversely  and  antero- 
posteriorly.     The  dotted  lines  represent  the  soft  palate. 

1.  Is  V-shaped  (deformed),  transversely  but  more  normal  antero- 
posteriorly. 

2.  Is  saddle-shaped  (deformed),  transversely  and  very  deformed 
antero-posteriorly.  That  shape  is  very  common  in  the  adolescent 
insane  and  in  idiots. 

3.  4,  and  5.   Show  various  kinds  of  the  "  Neurotic  "  type  of  palate. 
6.  Approaches  the  "  Typical."' 


p.  739        PLATE  XII. 


SECTIONS   OF   PALATES  IN    ADOLESCENT  INSANITY. 

(Vertical  transverse  and  anlero-poslerior). 


PLATE  XIII. 

Fig.  1.  Normal  large  pyramid ical  nerve  cells  of  frontal  cortex 
(human).  Bevan  Lewis's  fresh  method,  x  500.  The  case  was  one 
from  Royal  ICdiiiburgJi  Inlirmary,  in  wliich  death  occurred  from 
fracture  of  skull. 

Fig.  2.  Large  pyramidal  nerve  cells  of  frontal  cortex,  showing  first 
stage  of  pigmentary  degeneration.  The  cells  are  slightly  swollen, 
and  their  protoplasm  stains  deeply,  obscuring  the  pigment.  The 
processes  are  intact.  From  a  case  of  epilepsy.  Bevan  Lewis's  fresh 
raethdd.      x  500. 

Fig.  .3.  Large  pyramidal  nerve  cells  of  frontal  cortex,  showing 
second  stage  of  pigmentary  degeneration.  The  cells  are  beginning 
to  shririk,  their  protoplasm  stains  faintly,  the  cell-pigment  is  much 
increased  and  is  surrounded  by  a  "sclerosed  zone"  of  protoplasm, 
the  processes  stain  faintly,  and  some  of  them  are  stunted.  From 
a  case  of  general  paralysis.     Bevan  Lewis's  fresh  method.      x  500. 

Fig.  4.  Large  pyramidal  nerve  cells  of  frontal  cortex,  showing 
third  stage  of  pigjnentary  degeneiation.  The  cells  are  shrunken 
and  disintegi'ating.  The  remaining  piotoplasm  stains  faintly,  and 
contains  very  numerous  pigment  granules.  The  processes  have 
mostly  disappeared.  The  nucleus,  wlieu  present,  is  usually  faintly 
stained,  and  is  often  distorted.  Ultimately  only  a  few  grains  of 
yellow  pigment  are  left  re})resenting  the  cell.  From  a  case  of 
general  paralysis.     Bevan  Lewis's  fresh  method.      x  500. 

Fig.  5.  Large  pyramidal  nerve  cells  of  frontal  cortex,  showing 
granular  degeneration.  Tlie  protoplasm  is  filled  with  minute 
granules  of  a  pair;  yellow  colour.  Tliese,  however,  are  often  colour- 
less. From  a  case  of  alcoholic  insanity.  Bevan  I^ewis's  fresh 
method.      X  500. 

Fig.  6.  Large  jjyramidal  nerve  cells  of  frontal  cortex,  showing  a 
very  advanced  stage  of  granular  degeneration.  'l')ie  protoplasm  is 
faintly  stained  an<I  granular.  The  )iuclei  are  also  faintly  stained, 
and  altered  in  sliape  and  vacuolated  or  granular.  From  a  case  of 
chronic  melancholia.     Bevan  Lewis's  fresh  method.      x  500. 

Note. — Tlie  drawings  in  tlii.s  aiul  the  two  following'  Plates  were  drawn  by 
Dr  W.  F.  Robertson,  PaUioIngist  to  II.  E.  Asjiiiiii. 


p.  740        PLATE    XI 11. 


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PLATE   XIV. 

Fig.  1.  Pia  mater  and  first  and  second  layers  of  frontal  cortex, 
from  a  case  of  advanced  general  paralysis.  Bevan  Lewis's  fresh 
method.  x  400.  The  pia  mater  (a)  is  greatly  thickened  and 
infiltrated  witli  round  cells.  The  cortical  capillaries  (b)  are 
thickened  arid  granular,  and  show  an  increase  in  the  number  of 
their  nuclei.  The  spider  cells  (f)  in  the  first  layer  are  greatly 
hypertrophied.  Their  thickened  processes  may  form  a  layer  of 
felting  {(l)  below  the  pia.     The  nerve  cells  (e)  are  much  degenerated. 

Fig.  2.  Frontal  cortex  at  the  level  of  the  large  pyramidal  nerve 
cells,  from  a  case  of  advanced  general  paralysis.  Bevan  Lewis's 
fresh  method.  x  500.  The  capillaries  (a)  are  thickened  and 
granular,  and  show  an  increase  in  the  number  of  their  nuclei.  The 
neuroglia  cells  (6)  and  their  processes  are  very  greatly  hyper- 
trophied.    The  nerve  cells  (c)  show  advanced  degenerative  changes. 


p.  741        PLATE  XIV. 


/v,  J 


Fy.    2. 


PLATE   XV. 

Fig.  1.  Normal  capillaries  of  human  cerebral  cortex.  Bevan 
Lewis's  fresh  method.      x  500. 

Fig.  2.  Capillaries  of  cerebral  cortex  from  a  case  of  advanced 
general  paralysis,  showing  marked  thickening  and  granularity,  and 
increase  in  number  of  nuclei.     Bevan  Lewis's  fresh  method,     x  500. 

Fig.  3.  Normal  arteriole  of  human  cerebral  cortex.  Bevan 
Lewis's  fresh  method.      x  300. 

Fig.  4.  Cerebral  arteriole  from  a  case  of  advanced  general 
paralysis,  showing  dense  aggregation  of  round  cells  upon  its  walls, 
and  the  processes  of  hypertrophied  spider  cells  attached  to  it. 
Bevan  Lewis's  fresh  method.      x  300. 

Fig.  5.  Cerebral  arteriole  from  a  case  of  alcoholic  insanity,  show- 
ing generiil  fibroiis  thickening  and  localised  nellidar  aggregations. 
Bevan  Lewis's  fresh  method.      x  300. 

Fig.  6.  Normal  small  pyramidal  nerve  cells  of  third  layer  of 
cerebral  cortex  of  child.      Bevan  Lewis's  fresh  method.       x    500. 

Fig.  7.  Nerve  cells  of  cerebral  cortex  of  full-time  foetus.  Bevan 
Lewis's  fresh  method.      x  500. 

Fig.  S.  Nerve  cells  of  third  layer  of  cerebral  cortex,  from  a  case 
of  epileptic  idiocy.  [Patient  aged  24.]  Bevan  Lewis's  fresh  method. 
X  500.  'J'he  nerve  cells  closely  resemble  those  of  the  foetus,  the 
only  difference  being  that  they  show  a  degree  of  granular  change  in 
their  protoplasm.  A  comparison  of  these  two  specimens  (7  and  8) 
is  most  instructive  as  showing  one  stage  in  normal  brain  cell 
development  in  Fig.  7,  and  morbidly  arrested  development  in 
Fig.  8  ;  each  coi'responding  to  the  respective  mental  developments 
of  the  mdividuals  from  whose  brains  they  were  taken. 

Fig.  9.  Large  pyramidal  nerve  cells  of  frontal  cortex,  from  a  case 
of  senile  insanity  in  a  patient  aged  85.  Bevan  Lewis's  fresh  method. 
x  500.  They  show  advanced  pigmentary  degeneration,  with  loss 
of  many  of  their  processes. 

Fig.  10.  Large  pyramidal  nerve  cells  of  frontal  cortex,  from  a  case 
of  secondary  dementia.  Patient  had  an  attack  of  mania  at  the  age  of 
21 ,  which  was  not  recovered  from.  He  died  at  the  age  of  32,  from 
phthisis.  Bevan  Lewis's  fresh  method.  x  500.  The  nerve  cells 
show  marked  granular  change  in  their  protoplasm,  and  many  of 
their  processes,  more  especially  the  apical,  are  stunted. 


742        PLATE  XV. 


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COLUMBIA   UNIVERSITY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing 
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DATE  BORROWED 

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' 



RC601  C62 

1897 
Clouston 
Clinical  lectures  on  mental  dis- 


